1. society
2. crime
3. personal offense
4. assault

Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Medical Protocol/Guidelines for Management of Victims of
Gender Based Violence (including sexual violence)
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Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Content Index
Part 1 Overview and basic information about Gender-Based
Violence
Protecting human rights
What is Gender-Based Violence?
Defining Key Concepts.
Types of Gender-Based Violence.
When and where does Gender-Based Violence Occur?
Causes and Consequences of Gender-Based Violence
Legal and security safeguards in Egypt against Gender based
violence
Key Points to Remember.
Part 2 Guiding Principles for Management of GBV
Roles and responsibilities of health care provider.
The Relevance of Screening for GBV.
How to overcome barriers?
Challenges Preventing Women from Disclosing GBV.
Part 3 Provider’s Guide for Management of Domestic Violence DV
Guidelines step by step
Tactics of control and clinical cues
When to consider domestic violence even if the patient does not
disclose abuse
Sample Screening Tool for Suspected Cases
Medical history and examination form
Danger assessment instrument
Safety plan
Part 4 Provider's guide for clinical management of rape/sexual
violence
Introduction
Preparations required to offer appropriate medical care to victims of
rape
Steps to deal with a sexually abused person
STEP 1 – Preparing the victim for the examination
STEP 2 – Taking the history
STEP 3 – Collecting forensic evidence
STEP 4 – Performing the physical and genital examination
STEP 5 – Prescribing treatment
STEP 6 – Counseling the patient
STEP 7 - Follow-up care of the survivor
Care of child survivor
Part 5 Appendix
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Annex 1 Legal and security safeguards in Egypt against GBV
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
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Annex 2 History and examination form
Annex 3 Psychological First Aid
Annex 4 ‫تقرير طبي إصابى إبتدائي و ضوابط كتابة التقرير الطبي‬
Annex 5 Sexual Assault Forensic Examiner (SAFE)
Annex 6 Pictogram
Annex 7 STDs protocol
Annex 8
Annex 9
Annex 10 Referral Networks
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter one - Overview and basic information about GBV (including sexual violence)
Overview and basic information about
Gender-Based Violence (including sexual violence)
Contents
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Protecting human rights
What is Gender-Based Violence?
Defining Key Concepts.
Types of Gender-Based Violence.
When and where does Gender-Based Violence Occur?
Causes and Consequences of Gender-Based Violence
Key Points to Remember.
Gender-based violence is a violation of human rights. This kind of violence perpetuates the
stereotyping of gender roles that denies human dignity of the individual and stymies human
development. The overwhelming majority of the victims/survivors of gender-based violence
(including sexual violence) are women and girls.
Gender-based violence includes much more than sexual assault and rape. Although it may
occur in public contexts, it is largely rooted in individual attitudes that condone violence within
the family, the community and the State. The root causes and consequences of gender-based
violence must be understood before appropriate programmes to prevent and respond to this
violence can be planned.
A Few Facts about Gender-Based Violence
World-wide, an estimated 40 to 70 per cent of homicides of women are committed
by intimate partners, often in the context of an abusive relationship.
Around the world, at least one in every three women has been beaten, coerced into
sex, or otherwise abused in her lifetime.
Trafficking of humans world-wide grew almost 50 percent from 1995 to 2000 and
the International Organization for Migration (IOM) estimates that as many as 2
million women are trafficked across borders annually.
More than 90 million African women and girls are victims of female genital
mutilation.
At least 60 million girls who would otherwise be expected to be alive are missing
from various populations, mostly in Asia, as a result of sex-selective abortions,
infanticide or neglect.1
Domestic Violence is worldwide spread
 Between 21% and 37% of women experience domestic violence during their lifetimes.2
1
Violence Against Women: The Hidden Health Burden (World Bank 1994) Fact Sheet on Gender Violence: A
Statistics for Action Fact Sheet (L. Heise, IWTC, 1992 and Progress of the World’s Women (UNIFEM, 2000)
2
Campbell AS, Schollenberger J, Gielen, AC et al. 1999. Annual and lifetime prevalence of partner abuse in a
sample of female HMO enrollees. Women’s Health Issues 9(6): 295-305.
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Chapter one - Overview and basic information about GBV (including sexual violence)
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Research in primary care settings indicates that 3.4-5.5% of patients have experienced
domestic violence within the last year.3
Women aged 16 to 24 experience the highest rate of partner violence per capita.4
The reported rate of teen dating violence among adolescents varies from 25-60%.5
A national survey of 6,000 American families revealed that 50% of the men who frequently
assaulted their wives, also frequently abused their children.6
Approximately 14% of women being treated in emergency departments were victims of
domestic violence within the last year.7
Studies estimate that between 3% and 5% of the elderly population have been abused.
The Senate Special Committee on Aging estimates that there may be as many as 5 million
elders abused every year.8
The situation in Egypt
- Data from recent DHS 2005 showed that one in every three women is a victim of domestic
violence. Approximately 91% of married females are subjected to FGM/C in their early
adulthood. Harassments in public places are progressively increasing and becoming a
phenomenon.9
- 47% of married women surveyed report having experienced physical violence and 33% at
the hands of current or former husbands while only 1.3% of harmed women requested help
from the police10
- 57% of unmarried female youth in Egypt report being subject to physical violence by their
fathers and brothers. A public opinion poll on 13,500 female was conducted by the National
Council for Women (NCW) showed that 88% are circumcised, 38% forced to early marriage,
and 82% were subject to harassment11.
Human Rights
Prevention of and response to gender-based violence (including sexual violence) are directly
linked to the protection of human rights.
Human rights are universal, inalienable, indivisible, interconnected and interdependent. Every
individual, without regard to race, color, sex, language, religion, political or other opinion,
national or social origin, property, birth or status, is entitled to the respect, protection, exercise
and enjoyment of all the fundamental human rights and freedoms.
Governments are obliged to ensure the equal enjoyment of all economic, social, cultural, civil
and political rights for women and men, girls and boys.
3
Campbell AS, Schollenberger J, O’Campo PJ et al. 1999. Annual and lifetime prevalence of partner abuse in a
sample of female HMO enrollees. Women’s Health Issues 9(6): 295-305.
4
Rennison M. 2001. Intimate Partner Violence and Age of Victim, 1993-1999. Bureau of Justice Statistics:
Special Report. Washington, DC: U.S. Department of Justice. Publication NCJ 187635.
5
Cohall A, Cohall R, Banniester H et al. 1999. Love shouldn’t hurt: Strategies for healthcare providers to
address adolescent dating violence. J Am Med Women’s Assoc 54(3):144-8.
6
Strauss, M, Gelles R, Silverman J, and Smith C. 1990. Physical Violence in American Families: Risk Factors and
Adaptations to Violence in 8,145 Families. New Brunswick: Transaction Publishers.
7
Dearwater SR, Coben JH, Campbell JC et al. 1998. Prevalence of intimate partner abuse in women
8
National Center on Elder Abuse. 2003. (http://www.elderabusecenter.org/default.cfm?p=faqs.cfm#seven).
9
Demographic and Health Survey Egypt 2005
10
Study on Violence against women in Egypt –NCW 2009
11
National Council for Women (NCW) 2012
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Chapter one - Overview and basic information about GBV (including sexual violence)
Acts of gender-based violence violate a number of human rights principles enshrined in
international human rights instruments
Among others, these include:
 The right to life, liberty and security of the person.
 The right to the highest attainable standard of physical and mental health.
 The right to freedom from torture or cruel, inhuman, or degrading treatment or
punishment.
 The right to freedom of movement, opinion, expression, and association.
 The right to enter into marriage with free and full consent and the entitlement to equal
rights to marriage, during marriage and at its dissolution.
 The right to education, social security and personal development.
 The right to cultural, political and public participation, equal access to public services,
work and equal pay for equal work.
International Criminal Court defines rape, sexual slavery, enforced prostitution, forced
pregnancy, enforced sterilization or any other form of sexual violence of comparable gravity
as a crime against humanity.
What is Gender-Based Violence?
Sexual violence, gender-based violence and violence against women are terms that are
commonly used interchangeably. All these terms refer to violations of fundamental human
rights that perpetuate sex-stereotyped roles that deny human dignity and the selfdetermination of the individual and hamper human development.
They refer to physical, sexual and psychological harm that reinforces female subordination
and perpetuates male power and control.
While gender based violence has a devastating impact on the lives of women and
girls who are the majority of victims/survivors, it also hinders the development of
men and boys. Eliminating gender based violence and gender inequalities helps to
strengthen entire communities.
The term gender-based violence (GBV) is used to distinguish common violence from
violence that targets individuals or groups of individuals on the basis of their gender. Genderbased violence has been defined by the CEDAW12 Committee as violence that is directed at
a person on the basis of gender or sex. It includes acts that inflict physical, mental or sexual
harm or suffering, threat of such acts, coercion and other deprivations of liberty.
GBV shall be understood to encompass, but not be limited to the following:
a) Physical, sexual and psychological violence occurring in the family, including battering,
sexual exploitation, sexual abuse of children in the household, dowry-related violence, female
genital mutilation and other traditional practices harmful to women, non-spousal violence and
violence related to exploitation.
12
CEDAW: Convention on Elimination of All Forms of Discrimination Against Women UN 1979
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b) Physical, sexual and psychological violence occurring within the general community,
including rape, sexual abuse, sexual harassment and intimidation at work, in educational
institutions and elsewhere trafficking in women and forced prostitution.
c) Physical, sexual and psychological violence perpetrated or condoned by the State and
institutions, wherever it occurs.
The term violence against women refers to any act of gender-based violence that results in,
or is likely to result in, physical, sexual and psychological harm to women and girls, whether
occurring in private or in public. Violence against women is a form of gender-based violence
and it includes sexual violence.
Sexual violence, including exploitation and abuse, refers to any act, attempt or threat of a
sexual nature that results, or is likely to result, in physical, psychological and emotional harm.
Sexual violence is a form of gender-based violence.
Some organizations employ an inclusive conception of sexual and gender-based violence
that recognizes that, although the majority of victims/survivors are women and children, boys
and men are also targets of sexual and gender-based violence.
Sexual and gender-based violence is largely rooted in unequal power relations. These
perpetuate and condone violence within the family, the community and the State. The
distinction made between public and private spheres should not serve as an excuse for not
addressing domestic violence as a form of SGBV. The exclusion of women and girls from the
public arena only increases their vulnerability to violence within the family. Domestic violence
reinforces gender-based discrimination and keeps women subordinate to men.
Trafficking in persons shall mean the recruitment, transportation, transfer, harboring or
receipt of persons, by means of the threat or use of force or other forms of coercion, of
abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of
the giving or receiving of payments or benefits to achieve the consent of a person having
control over another person for the purpose of exploitation. Exploitation shall include, at a
minimum, the exploitation of the prostitution of others or other forms of sexual exploitation,
forced labor or services, slavery or practices similar to slavery, servitude or the removal of
organs.13
Defining Key Concepts
Sexual and gender-based violence includes much more than sexual assault and rape. To
understand its root causes and consequences, it is essential to define and distinguish between
the terms gender and sex.
The term sex refers to the biological characteristics of males and females. These
characteristics are congenital and their differences are limited to physiological reproductive
functions.
13
Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children,
supplementing the United Nations Convention against Transnational Organized Crime, November 2000
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Chapter one - Overview and basic information about GBV (including sexual violence)
Gender is the term used to denote the social characteristics assigned to men and women.
These social characteristics are constructed on the basis of different factors, such as age,
religion, national, ethnic and social origin. They differ both within and between cultures and
define identities, status, roles, responsibilities and power relations among the members of any
society or culture. Gender is learned through socialization. It is not static or innate, but evolves
to respond to changes in the social, political and cultural environment.
Gender is learned and therefore changeable.
People are born female or male (sex); they learn how to be girls and boys, and then become
women and men (gender). Gender refers to what it means to be a boy or girl, woman or man,
in a particular society or culture. Society teaches expected attitudes, behaviors, roles and
activities. Gender defines the roles, responsibilities, constraints, opportunities and privileges
of men and women in any context. This learned behavior is known as gender identity.
Women around the world are usually in a disadvantaged position compared to men of the
same social and economic levels. Gender roles and identities usually involve inequality and
power imbalance between women and men. Violence against women, and its acceptance
within society and cultures, is one of the manifestations of this inequality and power imbalance.
A comprehensive prevention and response plan should focus on the roles and needs of both
women and men and how both can become agents of change.
Focusing only on women when addressing sexual and gender-based violence tends to
place the responsibility for prevention and response on the victims/survivors.
Violence is a means of control and oppression that can include emotional, social or economic
force, coercion or pressure, as well as physical harm. It can be overt, in the form of a physical
assault or threatening someone with a weapon; it can also be covert, in the form of intimidation,
threats, persecution, deception or other forms of psychological or social pressure. The person
targeted by this kind of violence is compelled to behave as expected or to act against her will
out of fear. An incident of violence is an act or a series of harmful acts by a perpetrator or a
group of perpetrators against a person or a group of individuals. It may involve multiple types
and repeated acts of violence over a period of time, with variable durations. It can take
minutes, hours, days or a lifetime.
Abuse is the misuse of power through which the perpetrator gains control or advantage of
the abused, using and causing physical or psychological harm or inciting fear of that harm.
Abuse prevents persons from making free decisions and forces them to behave against their
will.
Coercion is forcing, or attempting to force, another person to engage in behaviors against
her will by using threats, verbal insistence, manipulation, deception, cultural expectations or
economic power.
Power is understood as the capacity to make decisions. All relationships are affected by the
exercise of power. When power is used to make decisions regarding one’s own life, it becomes
an affirmation of self-acceptance and self-respect that, in turn, fosters respect and acceptance
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of others as equals. When used to dominate, power imposes obligations on, restricts, prohibits
and makes decisions about the lives of others. To prevent and respond to sexual and genderbased violence effectively, the power relations between men and women, women and women,
men and men, adults and children, and among children must be analyzed and understood.
Exploitation and abuse occurs when this disparity of power is misused to the detriment of
those persons who cannot negotiate or make decisions on an equal basis. Exploitation and
abuse can take the form of physical and psychological force or other means of coercion
(threats, inducements, deception or extortion) with the aim of gaining sexual or other favors in
exchange for services.
Consent is when a person makes an informed choice to agree freely and voluntarily to do
something. The phrase against her will is used to indicate an absence of informed consent.
There is no consent when agreement is obtained through the use of threats, force or other
forms of coercion, abduction, fraud, deception, or misrepresentation.
The use of a threat to withhold a benefit, or a promise to provide a benefit, in order to obtain
the agreement of a person is also an abuse of power; any agreement obtained this way is not
considered to be consensual. There is also no consent if the person is below the legal
(statutory) age of consent or is defined as a child under applicable laws.
A perpetrator is a person, group, or institution that directly inflicts, supports and condones
violence or other abuse against a person or a group of persons. Perpetrators are in a position
of real or perceived power, decision-making and/or authority and can thus exert control over
their victims.
It is a myth that sexual and gender-based violence is usually perpetrated by strangers. In fact,
most acts of sexual and gender-based violence are perpetrated by someone known to the
survivor, and many violent incidents are planned in advance.
Sexual and gender-based violence can also be perpetrated by family and community
members. States and institutions condone and perpetrate sexual and gender-based violence
when discriminatory practices are not challenged and prevented, including through the use of
legal and policy instruments. During war and conflict, sexual and gender-based violence is
frequently perpetrated by armed members from warring factions.
Perpetrators of sexual and gender-based violence are sometimes the very people
upon whom survivors depend to assist and protect them.
Most cases of sexual and gender-based violence involve a female victim/survivor and a male
perpetrator. Most acts of sexual and gender-based violence against boys and men are also
committed by male perpetrators.
Intimate partners (husband, fiancée): In most societies, the accepted gender role for male
intimate partners is one of decision-making and power over the female partner. Unfortunately,
this power and influence is often exerted through discrimination, violence, and abuse.
Family members, close relatives and friends: Girls are far more likely to suffer sexual
and gender-based violence within the domestic sphere. From neglect to incest, these human
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rights violations are not always reported, since they involve fathers, stepfathers, grandfathers,
brothers and/or uncles as perpetrators. Harmful traditional practices also take place with the
knowledge and sometimes the participation of family members and close relatives and friends.
Influential community members (teachers, leaders, politicians, employers):
Leaders and other community members in positions of authority can abuse that power through
acts of sexual and gender-based violence. The victim/survivor in these situations is even more
reluctant to report the violence because of the perpetrator’s position of trust and power within
the community.
Institutions: Discriminatory practices in the delivery of social services help maintain and
increase gender inequalities. Withholding information, delaying or denying medical
assistance, offering unequal salaries for the same work and obstructing justice are some forms
of violence perpetrated through institutions.
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TYPES OF POWER AND CONTROL
Physical violence
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Using isolation
Hitting, punching, kicking
Withholding medications
Attempting to force miscarriage
Sexual violence
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Forced sexual activities
Forced prostitution or exotic dancing
Threatening to sexually abuse children
Using coercion or threats
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Making and/or carrying out threats to
hurt her
Threatening to leave her, to commit
suicide,
Making her drop existing charges
Using intimidation
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Making her afraid by using looks, actions
or gestures
Smashing things and destroying her
property
Displaying weapons as a threat to harm
her
Using emotional abuse
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Putting her down and making her feel
bad about herself
Making her think that she is “crazy”
Humiliating her and calling her names
including racial slurs
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Controlling what she does, who she
sees,
who she talks to and where she goes
Limiting her involvement with others
Using jealousy to justify his actions
Using economic abuse
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Preventing her from getting or keeping
a job
Forcing the victim to work “under the
table”
Taking the victim’s earned income
Using children
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Using children to relay intimidating or
threatening messages to her
Threatening to take children away from
her
Using visitation to harass her
Minimizing, denying and blaming
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Saying the abuse didn’t happen
Saying she caused the abuse
Making light of the abuse
Using assumed male privilege
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Expecting subservience based on her
perceived status as a woman
Treating her like a servant
Making relevant decisions unanimously
Being the one to define the male and
female roles in their relationship
Types of Gender-Based Violence (including sexual violence)
The following table describes some of the more common forms of sexual and gender-based
violence. The list is neither exhaustive nor exclusive. It is a practical tool that can be used in
each location to help identify the different forms of sexual and gender-based violence that
exist. Acts of sexual and gender-based violence have been grouped into five categories:
 Sexual violence.
 Physical violence.
 Emotional and psychological violence.
 Harmful traditional practices.
 Socio-economic violence.
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Chapter one - Overview and basic information about GBV (including sexual violence)
Sexual Violence
Type of act
Description/Examples
Can be perpetrated by
Rape
The invasion of any part of the body of
the victim or of the perpetrator with
a sexual organ, or of the anal or
genital opening of the victim with any
object or any other part of the body by
force, threat of force, coercion, taking
advantage of a coercive environment,
or against a person incapable of
giving genuine consent
(International Criminal Court).
Any act where a child is used for
sexual gratification. Any sexual
relations/interaction with a child.
Any person in a position of
power, authority and control,
including, intimate partner,
caregiver and stranger.
Child sexual
abuse,
defilement and
incest
Forced
sodomy/
anal rape
Attempted
rape or
attempted
forced sodomy
/anal rape
Sexual abuse
Sexual
exploitation
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Forced /coerced anal intercourse,
usually male-to-male or male-tofemale.
Attempted forced/coerced intercourse;
no penetration.
Someone the child trusts,
including parent, sibling,
extended family member,
friend or stranger, teacher,
elder, leader or any other
caregiver, anyone in a
position of power, authority
and control over a child.
Any person in a position of
power, authority and control.
Any person in a position of
power, authority and control.
Actual or threatened physical intrusion
of a sexual nature, including
inappropriate touching, by force or
under unequal or coercive conditions.
Any person in a position
power, authority and control,
family/community members,
co-workers, including
supervisors, strangers.
Any abuse of a position of
Anyone in a position of
vulnerability, differential power, or
power, influence, control,
trust for sexual purposes; this includes including humanitarian aid
profiting momentarily, socially or
workers, soldiers/officials at
politically from the sexual exploitation
checkpoints, teachers,
of another (IASC); Sexual exploitation smugglers, trafficking
is one of the purposes of trafficking in networks.
persons (performing in a sexual
manner, forced undressing and/or
nakedness, coerced marriage, forced
childbearing, engagement in
pornography or prostitution, sexual
extortion for the granting of goods,
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter one - Overview and basic information about GBV (including sexual violence)
services, assistance benefits, sexual
slavery).
Forced
prostitution
(also referred
to as sexual
exploitation)
Sexual
harassment
Forced/coerced sex trade in exchange
for material resources, services and
assistance, usually targeting highly
vulnerable women or girls unable to
meet basic human needs for
themselves and/or their children.
Any unwelcome, usually repeated and
unreciprocated sexual advance,
unsolicited sexual attention, demand
for sexual access or favors, sexual
innuendo or other verbal or physical
conduct of a sexual nature, display of
pornographic material, when it
interferes with work, is made a
condition of employment or
creates an intimidating, hostile or
offensive work environment.
Sexual
Crimes against humanity of a sexual
violence
nature, including rape, sexual slavery,
as a weapon of forced abortion or sterilization or any
war and torture other forms to prevent birth, forced
pregnancy, forced delivery, and forced
child rearing, among others. Sexual
violence as a form of torture is defined
as any act or threat of a sexual nature
by which severe mental or physical
pain or suffering is caused to obtain
information, confession or punishment
from the victim or third person,
intimidate her or a third person or
to destroy, in whole or in part,
a national, ethnic, racial or religious
group.
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Any person in a privileged
position, in possession of
money or control of material
resources and services,
perceived as powerful.
Employers, supervisors or
colleagues, any person in
a position of power,
authority, or control.
Often committed, sanctioned
and ordered by military,
police, armed groups or
other parties in conflict.
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter one - Overview and basic information about GBV (including sexual violence)
Physical Violence
Type of act
Description/Examples
Can be perpetrated by
Physical
assault
Beating, punching, kicking, biting,
burning, maiming or killing, with or
without weapons; often used in
combination with other forms of
sexual and gender-based violence.
Trafficking,
Slavery
Selling and/or trading in human
beings for forced sexual activities,
forced labor or services, slavery or,
servitude or removal of organs.
Spouse, intimate partner,
family member, friend,
acquaintance, stranger,
anyone in position of power,
members of parties to a
conflict.
Any person in a position of
power or control.
Emotional and Psychological Violence
Type of act
Description/Examples
Abuse/Humiliation Non-sexual verbal abuse that is
insulting, degrading, demeaning;
compelling the victim/survivor to
engage in humiliating acts, whether
in public or private; denying basic
expenses for family survival..
Confinement
Isolating a person from friends/family
restricting movements, deprivation of
liberty or obstruction/restriction of the
right to free movement.
Can be perpetrated by
Anyone in a position of
power and control; often
perpetrated by spouses,
intimate partners or family
members in a position of
authority.
Anyone in a position of
power and control; often
perpetrated by spouses,
intimate partners or family
members in a position of
authority.
Harmful Traditional Practices
Type of act
Description/Examples
Can be perpetrated by
Female genital
mutilation
(FGM)
Cutting of genital organs for nonmedical reasons, usually done at
a young age; ranges from partial
to total cutting, removal of genitals,
stitching whether for cultural or other
non-therapeutic reasons; often
undergone several times during
life-time, i.e., after delivery or if
a girl/woman has been victim of
sexual assault.
Arranged marriage under the age of
legal consent (sexual intercourse in
such relationships constitutes
statutory rape, as the girls are not
Traditional practitioners,
health providers (in some
countries), supported,
condoned, and assisted by
families, religious groups,
entire communities and
some States.
Early marriage
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Parents, community and
State.
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter one - Overview and basic information about GBV (including sexual violence)
Forced
marriage
Honor killing
and maiming
Infanticide
and/or neglect
Denial of
education for
girls or women
legally competent to agree to such
unions)
Arranged marriage against the
victim’s/survivor’s wishes; often
a dowry is paid to the family; when
refused, there are violent and/or
abusive consequences.
Maiming or murdering a woman or girl
as punishment for acts considered
inappropriate for her gender that are
believed to bring shame on the family
or community (e.g., pouring acid on
a young woman’s face as punishment
for bringing shame to the family for
attempting to marry someone not
chosen by the family), or to preserve
the honor of the family (i.e., as
a redemption for an offence
committed by a male member of the
family).
Killing, withholding food, and/or
neglecting female children because
they are considered to be of less
value in a society than male children.
Removing girls from school,
prohibiting or obstructing access of
girls and women to basic, technical,
professional or scientific
knowledge.
Parent, family members.
Parent, husband, other
family members or members
of the community.
Parent, other family
members.
Parents, other family
members, community, some
States.
Socio-Economic Violence
Type of act
Description/Examples
Can be perpetrated by
Discrimination
and/or denial
of
opportunities,
services
Obstructive
legislative
practice
Exclusion, denial of access to
education, health assistance or
remunerated employment; denial
of property rights.
Family members, society,
institutions and
organizations, government
actors.
Denial of access to exercise and
enjoy civil, social, economic, cultural
and political rights, mainly to women.
Family, community,
institutions and State.
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Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter one - Overview and basic information about GBV (including sexual violence)
When and where does Gender-Based Violence Occur?
Gender-based violence can occur anywhere, at any time. It is used as a weapon of war; it is
perpetrated in the supposed safety of one’s home. Just as the laws and structures that govern
a society influence the behavior of individuals, so, too, can individual attitudes influence the
way families, communities and societies respond to certain types of behavior. The diagram
represents the clear linkages between the individual and the society.
At the individual level, the degree of knowledge, personal security, access to and control of
resources, services and social benefits, personal history and attitudes towards gender can
influence whether a person will become a victim/survivor or a perpetrator of violence.
The second level, relationship, represents the immediate context in which abuse can occur:
between individuals, even within families. At this level, existing power inequalities among
individuals begin to reinforce subordinate/privileged positions.
The community level represents the dynamics between and among people that are influenced
by socialization within such local structures as schools, health care institutions, peer groups
and work relationships. Society includes the cultural and social norms about gender roles,
attitudes towards children, women and men, the legal and political frameworks that govern
behavior, and the attitude towards using violence as means of resolving conflicts. It is clear to
see that changes in behavior and attitudes in any one of the areas can have an impact on all
of them. Interventions to prevent or respond to sexual and gender-based violence should thus
target all levels.
Gender based violence (including sexual violence) occurs in all classes, cultures,
religions, races, gender and ages.
Gender-Based Violence during the Life Cycle
The following table describes the forms of violence to which women can be subjected to
during the different stages of their lives.
Phase
Pre-birth
Infancy
Girlhood
16 Page
Type of violence Present
Sex-selective abortion; battering during pregnancy; coerced pregnancy.
Female infanticide; emotional and physical abuse; differential access to
food and medical care.
Child marriage; genital mutilation; sexual abuse by family members and
strangers; differential access to food, medical care and education.
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter one - Overview and basic information about GBV (including sexual violence)
Adolescence
Reproductive
age
Elderly
17 Page
Violence during courtship; economically coerced sex (e.g. for school
fees); sexual abuse in the workplace; rape; sexual harassment;
arranged marriage; trafficking.
Physical, psychological and sexual abuse by intimate male partners
and relatives; forced pregnancies by partner; sexual abuse in the
workplace; sexual harassment; rape; abuse of widows, including
property grabbing and sexual cleansing practices.
Abuse of widows, including property grabbing; accusations of
witchcraft; physical and psychological violence by younger family
members; differential access to food and medical care.
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter one - Overview and basic information about GBV (including sexual violence)
Causes and Consequences of Gender-Based Violence (including
sexual violence)
To plan appropriate programmes to prevent and respond to sexual and gender-based
violence, it is important to analyze the causes and consequences of such violence in each
setting. Understanding the causes will help you to develop effective actions to prevent the
violence; understanding the consequences allows you to develop appropriate response
packages for victims/survivors.
CAUSES > Prevention activities
CONSEQUENCES > Response activities
Causes of Sexual and Gender-Based Violence
The root causes of sexual and gender-based violence lie in a society’s attitudes towards and
practices of gender discrimination, which place women in a subordinate position in relation to
men. The lack of social and economic value for women and women’s work and accepted
gender roles perpetuate and reinforce the assumption that men have decision-making power
and control over women. Through acts of sexual and gender-based violence, whether
individual or collective, perpetrators seek to maintain privileges, power and control over others.
Gender roles and identities are determined by sex, age, socio-economic conditions, ethnicity,
nationality and religion. Relationships between male and female, female and female, and male
and male individuals are also marked by different levels of authority and power that maintain
privileges and subordination among the members of a society. The disregard for or lack of
awareness about human rights, gender equity, democracy and non-violent means of resolving
problems help perpetuate these inequalities.
Contributing Risk Factors
While gender inequality and discrimination are the root causes of sexual and gender-based
violence, various other factors determine the type and extent of violence in each setting. It is
important to understand these factors in order to design effective strategies to prevent and
respond to sexual and gender-based violence.
Equal access to and control of material resources and
assistance benefits and women’s equal participation in
decision making processes should be reflected in all
programmes, whether explicitly targeting sexual and gender
based violence or responding to the emergency, recovery or
development needs of the population.
The following chart describes some causes or risk factors that can increase the risks of
becoming a victim/survivor or perpetrator of sexual and gender-based violence:
Causes or Risk Factors for SGBV
Individual risks
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



Loss of security
Dependence
Physical and mental disabilities
Lack of alternatives to cope with changes in socioeconomic status
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter one - Overview and basic information about GBV (including sexual violence)





Social norms and
culture

Legal framework and
practices in host
country and/or country
of origin














War and armed conflict
Refugee, returnee and
internally displaced
situations









19 Page
Alcohol, drug use/abuse
Psychological trauma and stress of conflict, flight,
displacement
Disrupted roles within family and community
Ignorance/lack of knowledge of individual rights
enshrined under national and international law
Discriminatory cultural and traditional beliefs and
practices
Religious beliefs
Discrimination and condone sexual and gender-based
violence
Lack of legal protection for women’s and children’s rights
Lack of laws against sexual and gender-based violence
Lack of trust in the law enforcement authorities
Application of customary and traditional laws and
practices that enforce gender discrimination
General insensitivity and lack of advocacy campaigns
condemning and denouncing sexual and gender-based
violence
Discriminatory practice in justice administration and law
enforcement
Under-reporting of incidents and lack of confidence in
the administration of justice
Lack of willingness to effectively prosecute all cases
reported to authorities
Low number of prosecutions obtained in proportion to
the number of cases reported
Police and courts inaccessible because of remote
location of camp
Absence of female law enforcement officers
Lack of administrative resources and equipment by local
courts and security officials
Laws or practices in the administration of justice that
support gender
Breakdown of social structures
Exertion of political power and control
Ethnic differences
Socio-economic discrimination
Collapse of social and family support structures
Geographical location and local environment (high crime
area)
Design and social structure of camp (overcrowded, multihousehold dwellings, communal shelter)
Design of services and facilities
Predominantly male camp leadership; gender-biased
decisions
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter one - Overview and basic information about GBV (including sexual violence)






Unavailability of food, fuel, income generation, leading to
movement in isolated areas
Lack of police protection
Lack of UNHCR/NGO presence in camp
Lack of security patrols
Lack of individual registration and identity cards
Hostility of local population (refugees are considered
materially privileged)
Consequences of Sexual and Gender-Based Violence
Rape or sexual assault is a traumatic experience, both emotionally and physically. Survivors
may have been raped by a number of people in a number of different situations; they may
have been raped by strangers, friends, fathers, uncles or other family members; they may
have been raped while working in field, using the latrine, in their beds or visiting friends.
They may have been raped by one, two, three or more people, by men or boys, or by women.
They may have been raped once or a number of times over a period of months. Survivors may
be women or men, girls or boys; but they are most often women and girls, and the perpetrators
are most often men.
Survivors may react in any number of ways to such a trauma; whether their trauma reaction
is long-lasting or not depends, in part, on how they are treated when they seek help. By
seeking medical treatment, survivors are acknowledging that physical and/or emotional
damage has occurred. They most likely have health concerns. The health care provider can
address these concerns and help survivors begin the recovery process by providing
compassionate, thorough and high-quality medical care, by centering this care around the
survivor and her needs, and by being aware of the setting-specific circumstances that may
affect the care provided.14
Victims/survivors of sexual and gender-based violence are at high risk of severe health and
psycho-social problems, sometimes death, even in the absence of physical assault.
The potential for debilitating long-term effects of emotional and physical trauma should never
be underestimated. Understanding the potential consequences of sexual and gender-based
violence will help actors to develop appropriate strategies to respond to these after effects
and prevent further harm. A sectoral breakdown is used in the following summary of
consequences.
Health
There are serious and potentially life threatening health outcomes with all types of sexual
and gender-based violence.
Fatal Outcomes
 Homicide
 Suicide
 Maternal mortality
 Infant mortality
14
Center for Health and Gender Equity (CHANGE)
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
Non-Fatal
Outcomes
AIDS-related mortality
Acute Physical
 Injury
 Shock
 Disease
 Infection
Chronic Physical
 Disability
 Somatic complaints
 Chronic infections
 Chronic pain
 Gastrointestinal
 problems
 Eating disorders
 Sleep disorders
 Alcohol/drug abuse
Reproductive
 Miscarriage
 Unwanted
pregnancy
 Unsafe abortion
 STIs, including
HIV/AIDS
 Menstrual
disorders
 Pregnancy
complications
 Gynecological
disorders
 Sexual disorders
Psycho-Social
Emotional & Psychological
Consequences
 Post traumatic stress
 Depression
 Anxiety, fear
 Anger
 Shame, insecurity, self-hate,
self-blame
 Mental illness
 Suicidal thoughts, behavior


Social Consequences






Blaming the victim/survivor
Loss of role/functions in
society (e.g. earn income,
child care)
Social stigma
Social rejection and isolation
Feminization of poverty
Increased gender inequalities
Most societies tend to blame the victim/survivor. This social rejection results in further
emotional damage, including shame, self-hate and depression.
As a result of the fear of social stigma, most victims/survivors never report the incident.
Indeed, most incidents of sexual and gender-based violence go unreported.
Legal/Justice


If national laws do not provide adequate safeguards against sexual and gender-based
violence, or if practices in the judicial and law enforcement bodies are discriminatory, this
kind of violence can be perpetrated with impunity.
Community attitudes of blaming the victim/survivor are often reflected in the courts. Many
sexual and gender-based crimes are dismissed or guilty perpetrators are given light
sentences. In some countries, the punishment meted out to perpetrators constitutes
another violation of the victim’s/survivor’s rights and freedoms, such as in cases of forced
marriage to the perpetrator. The emotional damage to victims/survivors is compounded by
the implication that the perpetrator is not at fault.
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Chapter one - Overview and basic information about GBV (including sexual violence)
Safety/Security



The victim/survivor is insecure, threatened, afraid, unprotected and at risk of further
violence.
When dealing with incidents of trafficking in persons, police and security workers are at
risk of retaliation.
If police and security workers are not sensitive to the victim’s/survivor’s needs for
immediate care, dignity and respect, further harm and trauma may result because of
delayed assistance or insensitive behavior.
Legal and security safeguards in Egypt against Gender based
violence
International conventions ratified by Egypt addressing GBV (please refer to annex 1)

Convention on Elimination of All Forms of Discrimination Against Women –
ratified by Egypt in 1981
Article 2
States Parties condemn discrimination against women in all its forms, agree to pursue
by all appropriate means and without delay a policy of eliminating discrimination
against women and, to this end, undertake:
(a) To embody the principle of the equality of men and women in their national
constitutions or other appropriate legislation if not yet incorporated therein and to
ensure, through law and other appropriate means, the practical realization of this
principle;
(b) To adopt appropriate legislative and other measures, including sanctions where
appropriate, prohibiting all discrimination against women;
(c) To establish legal protection of the rights of women on an equal basis with men and
to ensure through competent national tribunals and other public institutions the
effective protection of women against any act of discrimination;
(f) To take all appropriate measures, including legislation, to modify or abolish existing
laws, regulations, customs and practices which constitute discrimination against
women;

Convention on the Rights of the Child – CRC, ratified by Egypt in 1990 (Egypt
was one of the first 20 states to ratify the CRC)
Article (19)
1. States Parties shall take all appropriate legislative, administrative, social and
educational measures to protect the child from all forms of physical or mental
violence, injury or abuse, neglect or negligent
2. Treatment, maltreatment or exploitation, including sexual abuse, while in the care
of parent(s), legal guardian(s) or any other person who has the care of the child.
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Chapter one - Overview and basic information about GBV (including sexual violence)

International Conference on Population and Development- ICPD, hosted in
Egypt in 1994.
4.9. Countries should take full measures to eliminate all forms of exploitation, abuse,
harassment and violence against women, adolescents and children. This implies both
preventive actions and rehabilitation of victims. Countries should prohibit degrading
practices, such as trafficking in women, adolescents and children and exploitation
through prostitution, and pay special attention to protecting the rights and safety of
those who suffer from these crimes and those in potentially exploitable situations, such
as migrant women, women in domestic service and school girls. In this regard,
international safeguards and mechanisms for cooperation should be put in place to
ensure that these measures are implemented.
4.10. Countries are urged to identify and condemn the systematic practice of rape and
other forms of inhuman and degrading treatment of women as a deliberate instrument
of war and ethnic cleansing and take steps to assure that full assistance is provided to
the victims of such abuse for their physical and mental rehabilitation.

Geneva Convention IV- ratified by Egypt in 1952.
Article (27) “…. Women shall be especially protected against any attack on their
honour, in particular against rape, enforced prostitution, or any form of indecent
assault…”

Convention against Torture and Other Cruel, Inhuman or Degrading Treatment
or Punishment – ratified by Egypt in 1986
Article (1) “ …… the term "torture" means any act by which severe pain or suffering,
whether physical or mental, is intentionally inflicted on a person for such purposes as
obtaining from him or a third person information or a confession, punishing him for an
act he or a third person has committed or is suspected of having committed, or
intimidating or coercing him or a third person, or for any reason based on discrimination
of any kind, when such pain or suffering is inflicted by or at the instigation of or with
the consent or acquiescence of a public official or other person acting in an official
capacity”
Gender based violence in the Egyptian constitution of 2014 (please refer to
annex 1)
Article (11) “…… The State shall protect women against all forms of violence and
ensure enabling women to strike a balance between family duties and work
requirements. The state shall provide care to and protection of motherhood and
childhood, female heads of families, and elderly and neediest women.”
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Chapter one - Overview and basic information about GBV (including sexual violence)
The articles of criminal law on sexual assaults, rape, physical violence, FGM/C,
sexual harassment and Human Trafficking. (please refer to annex 1)
The Egyptian law criminalizes FGM/C, it enforces a prison sentence of 3 months- 2
years or a monetary penalty on the persons who perform FGM/C and/or the parent of
the victim of FGM/C, as per “Article 242 repeated” of the criminal law.
The Egyptian law criminalizes verbal and physical acts of sexual harassment with a
prison sentence of 6 months- 2 years and/or a monetary penalty, as per “Article 306
repeated” of the criminal Law.
Sexual assaults of males and females are criminalized with a prisoning sentence of
7 years up to life in prison, if the victim is below the age of 18 years old, as per “Article
268” of the Egyptian criminal law.
Rape is criminalized in the Egyptian criminal law by a sentence of life in prison or
execution as per “Articles 267 and 269”
All forms of Human trafficking are criminalized under the special law on Human
Trafficking 2010 as per the legal definition in Article 2 of the same law.
The Egyptian Law criminalizes all acts of violence, as per “Article 241” of the criminal
law by a prison sentence of maximum of 2 years or a monetary penalty in cases where
the assault results in more than 20 days of hospitalization. The prison sentence is
obligatory in the case of use of tools or weapons. According to “Article 240”, violent
acts resulting in the loss of body functions or loss of body organs leading to a
permanent disability, the perpetrator shall be subject to a prison sentence of 3-5 years.
Domestic Violence or violence inside the household is not addressed in specific in the
Egyptian criminal law other than in the above Articles.
The role of the Department of the Human Rights at the Ministry of Justice
The unit of “Combating Violence against Women” pertaining to the Department of the
Human Rights at the Ministry of Justice was established by a ministerial decree. The
unit is taking the lead in strengthening collaboration between the various justice and
law enforcement departments and agencies to ensure adequate timely response
through providing victims with access to justice, as well as, bringing perpetrators to
justice.
The role of the VAW Unit at the Ministry of Interior
The “Violence against Women” unit at the Ministry of Interior has been established by
the ministerial decree No. 2285 for the year 2013. The unit is mandated to follow-up
on cases where women are subject to violence to ensure that all adequate legal
proceedings have been taken and to provide the required psychological and social
support for the victims to overcome the effects of the attack. An additional extension
of the central VAW unit in August 2014 has approved the establishment of a VAW
unit in every governorate.
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Chapter one - Overview and basic information about GBV (including sexual violence)
-
-
The main role of the Unit is:
To conduct research and investigation on cases of violence against women,
To provide victims of violence with adequate support and protection throughout the
various steps of the investigation process, including legal literacy (providing legal
information) throughout the stages of proceedings,
To raise community awareness on the harms of violence against women and work on
promoting a conducive culture that encourages reporting of cases of violence.
The social protection networks available (Shelters, Ombudsman offices, etc.)
(please refer to annex10 Referral networks)
Governmental and non-governmental entities providing various types of support
services to victims of violence which include but are not limited to: legal counseling,
legal literacy, legal assistance, psyco-social support, shelters for women who are
facing severe violence or danger in their homes, ..etc.
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Chapter one - Overview and basic information about GBV (including sexual violence)
Key Points to Remember
Sexual and gender-based violence violates human rights. Preventing and responding
to sexual and gender-based violence against people is thus part of the overall strategy
to protect human rights.
Women and girls make up the vast majority of victims/survivors of sexual and genderbased violence, although boys and men can also be victims/survivors.
Gender refers to what it means to be a boy or girl, woman or man, in a particular society
or culture.
A comprehensive prevention and response plan should focus on the roles and needs
of both women and men and how both can become agents of change.
Most acts of sexual and gender-based violence are perpetrated by someone known to
the survivor.
Perpetrators of sexual and gender-based violence are sometimes the very people
upon whom survivors depend to assist and protect them.
Sexual and gender-based violence occurs in all classes, cultures, religions, races,
gender and ages. Interventions to prevent or respond to sexual and gender-based
violence should target individuals, close relationships, the community and society, in
general.
Understanding the causes of sexual and gender-based violence will help us to develop
effective actions to prevent it; understanding the consequences of sexual and genderbased violence allows us to develop appropriate response packages for
victims/survivors.
Gender inequality and discrimination are the root causes of sexual and gender-based
violence.
Equal access to and control of material resources and assistance benefits and
women’s equal participation in decision-making processes should be reflected in all
programmes, whether explicitly targeting sexual and gender-based violence or
responding to the emergency, recovery or development needs of the population.
The potential for debilitating long-term effects of emotional and physical trauma should
never be underestimated.
The Egyptian laws and International conventions ratified by Egypt criminalize GBV.
The main source of this chapter is "Sexual and Gender-Based Violence against Refugees,
Returnees and Internally Displaced Persons", a product of UNITED NATIONS HIGH
COMMISSIONER FOR REFUGEES May 2003
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Chapter two – Guideline Principles for Management of GBV
Guiding Principles for Management of GBV
Contents

Roles and responsibilities of health care provider.

The Relevance of Screening for GBV.

How to overcome barriers?

Challenges Preventing Women from Disclosing GBV.
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Chapter two – Guideline Principles for Management of GBV
Role of health care provider
Healthcare professionals play a crucial role in identifying victims of GBV because they have a
regular opportunity to ask patients about GBV, regardless of the reason for the medical visit.
By screening patients for GBV, healthcare professionals can assist victims who may not seek
assistance elsewhere. By directly asking patients about violence, regardless of symptoms,
injuries or reason for the visit, there is an increased likelihood that victims will disclose abuse.
Given medical practitioners’ specific roles and time constraints, responding to GBV can be
challenging. This guide explores methods of overcoming these challenges and intends to
assist practitioners to efficiently identify GBV victims, intervene effectively, and provide
meaningful referrals. It is key that each GBV case is approached systemically while having
each professional limit his/her role by area of expertise.
What Health Care Provider Should Know






How to manage the screening process for suspected cases in a time efficient manner
How to manage the care of a patient who discloses GBV and/or DV (Domestic
Violence)
How to screen a patient when the abuser accompanies her to the appointment
Challenges that prevent women from disclosing abuse
The importance of documentation for a complete diagnosis
The importance of effective referral system and networking with other support and
safety services
Roles & Responsibilities Matrix15
Health care provider
Preparing the victim for
the examination
First aid psychological
support
Taking the history
including screening
questions for suspected
cases
Collecting forensic
evidence16
Performing general
physical examination
Physician at
primary health
care center
Physician at
district or
governorate
hospital
√
√
√
√
√
√
√
√
√
Nurse
Social
worker
√
√
√
√
√
Attendance
required
√
√
Attendance
required
15
Identification of roles and responsibilities of service providers at various levels as per the recommendations
of the High Committee developing the GBV Medical Protocol and validated by the Ministry of Health and
Population in Egypt – MOHP
16
Trained MOHP health service providers on Sexual Assault Forensic Examiner (SAFE) training conducted by
Forensic Medicine Department at Ministry of Justice
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Chapter two – Guideline Principles for Management of GBV
Performing genital
examination(inspection)
√
√
Performing genital
examination(internal)
Laboratory testing
√
Attendance
required
Call gynecologist
Referral
Prescribing treatment
First aid treatment:
suturing wounds,
support vital function, ….
Tetanus toxoid
√
√
√
√
√
√ oral
√ + IUCD
Hepatitis B vaccine
Emergency
contraception
Prophylactic STDs
√
PEP for HIV
Psychological first aid
√
√
assistance
√
assistance
√
assistance
√
√ or Referral
√
Psychological
counselling
Documentation and
registration in GBV
logbook
Medical certificate
√
√
Reporting to legal
authorities
√
√
√
29 Page
√
assistance
√
√
√
√
Referral
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
The Relevance of Screening for GBV17
Screening is critical for the prevention and detection of GBV
as well as the effective management of patient care.
Failure to
identify
GBV may
have serious
consequences
Possible negative health outcomes
Unnecessary testing and misdiagnoses.
Complications during pregnancy.
Increased risk of chronic illness such as abdominal pain,
migraines, sexually transmitted infections, HIV, depression
and other conditions.
Victims are
unlikely to
voluntarily
disclose their
abuse
In America, 57% of abused women have never told anyone about
their abusive situation. Of the women who received domestic
violence services in a large healthcare network, 95% had not
previously sought treatment from any other organization.
 You may be the only person to inquire about the abuse
before it results in adverse health consequences.
Opportunity for
the healthcare
provider to
intervene
You may be seeing patients who are victims of abuse, but are
seeking medical care for other reasons.
Researchers concluded that prenatal and postpartum clinic
visits present an ideal situation for the doctor to prevent
injury to pregnant women.
Women who are battered during pregnancy are more likely
to seek healthcare for injuries than women battered before
pregnancy.
 When you pick up a case of GBV and make referrals to
relevant providers, you communicate your concern about
this issue, validate the victim’s experience and provide an
opportunity for her to legitimately seek help.
Relevance of
screening for
GBV
Those who favors routine screening for GBV say that by asking
your patient about possibility of violence, you may achieve the
following positive outcomes:
Prevent physical and mental health problems caused by
GBV;
Improve the quality of life of the victim’s children;
17
This section is mainly adapted from MEDICAL PROVIDERS’ GUIDE TO MANAGING THE CARE OF DOMESTIC
VIOLENCE PATIENTS WITHIN A CULTURAL CONTEXT 2nd edition. Product of the New York City Mayor's Office to
Combat Domestic Violence 2004
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Chapter two – Guideline Principles for Management of GBV
Protect the victim’s friends, family and coworkers from harm
by the abuser;
Prevent the cycle of violence from damaging another
generation;
Affirm the significance of GBV as a public health issue; and
Reduce sick days and lost productivity in the workplace.
Selective screening for GBV can save the life of a victim of
abuse.
Prevalence of
DBV during
pregnancy
A substantial number of pregnant women are victims of GBV.
Approximately 240,000 pregnant women (6%) in the U.S. are
abused by an intimate partner annually.
Battering during pregnancy is associated with greater
severity than battering that occurred before pregnancy.
Abuse during pregnancy seems to be recurrent, with 60% of
abused women reporting two or more episodes of assault.
GBV risk
factors can be
identified in
pregnant
women
Research indicates an association between GBV and various risk
factors.
Lack of effective social support is more common among
pregnant victims of GBV.
Women with inadequate access to prenatal care are more
likely to be battered during pregnancy.
Women who have fewer places to go for assistance are at
greater risk of being assaulted.
Women battered during pregnancy are more likely to have
housing problems.
Possible Warning Signs of GBV in Pregnant Women
Medical care
Medical
Pregnancy
Mental health
utilization
conditions
Missed medical
Late entry into Chronic
History of
appointments
prenatal care
pelvic
suicide
pain
Attempts
Repeated visits
to the doctor
Young
maternal age
Recurrent
headaches
Depression
and anxiety
Regular medical
visits for injuries
History of
abuse or
assault
Unintended
pregnancy
Irritable
bowel
syndrome
Vaginitis
Unhappiness
about being
pregnant
Substance
abuse
Unscheduled
visits to the
doctor
 However, GBV may exist in the absence of any obvious
medical and behavioral warning signs, illustrating the
relevance of routine screening.
31 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
GBV/DV is an
obstetric risk
factor
Various associations exist between GBV/DV and obstetric
complications.
Abused women are more likely to have a poor obstetric
history than women who have not been abused.
Abused adolescents are more likely to experience first or
second trimester bleeding than adolescents who are not
being abused.
Physical violence during pregnancy is a significant predictor
of premature labor or delivery.
Women who are abused during pregnancy are at greater
risk of miscarriage or neonatal death.
Association
between
maternal illness
and abuse
There is a correlation between maternal morbidity and exposure to
violence during pregnancy.
Many women in abusive relationships also experience
sexual assault, and are in turn at increased risk of
contracting sexually transmitted infections.
There is a significant association between physical violence
and kidney infections in pregnant women.
83% of women who were battered during pregnancy
reported symptoms of depression.
89% of women being abused during pregnancy suffer from
symptoms of anxiety.
Abused women are more likely to smoke, use drugs and
use alcohol during their pregnancy than those who are not
in abusive relationships. A possible explanation of these
behaviors has been postulated as an attempt to manage the
heightened stress or trauma associated with being abused.
 A substantial percentage of women, including those who
are pregnant, are victims of GBV.
 Failure to identify GBV/DV as early as possible can result
in negative health outcomes, costly medical care and legal
implications.
 Victims are unlikely to voluntarily disclose their abuse,
reinforcing the relevance of selective screening.
 Members of the public generally take a medical
practitioner’s opinion seriously, providing an opportunity
for you to inquire about GBV/DV and to recommend
interventions.
 GBV/DV is a significant obstetric risk factor.
 The majority of pregnant women receive prenatal care,
enabling you to screen for GBV/DV during this time.
 While there is a definite association between various risk
factors and GBV, abuse may exist in the absence of
observable medical and behavioral evidence.
Summary
32 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
How to Overcome self Barriers?
Techniques to Overcome Barriers that Healthcare Provider May Encounter
Concerns of Healthcare Practitioners and Techniques to
Overcome Them
Is GBV/DV
screening
part of my job?
Despite time constraints and patient overload, GBV is an area of
increasing concern, and the medical profession plays a central
role in ending this problem.
In many cases, you may be the only person who can provide help
to the victim.
Not asking about abuse can result in adverse health
consequences or death for patients.
Not asking about abuse can lead to costly testing and
misdiagnoses.
GBV is a public health issue.
Many international medical organizations recommend screening
for GBV/DV.
What is the
medical
provider’s
role in the
screening and
intervention
process?
It is the practitioner’s role to identify and recognize the presence
of abuse, as well as to effectively manage patient care.
Screen for abuse.
Assess the medical context of the abuse (e.g. the severity and
frequency of injuries; whether food or medication are being
withheld from the patient).
Provide medical treatment for the presenting injuries.
Assess the safety of the victim.
Briefly counsel the victim regarding available resources and
management options.
Document your findings and referrals.
If the system permit take photos of the injuries.
Refer the patient to relevant specialty whenever indicated
What should I
do
if my patient
takes
offense when I
examine for
abuse?
If a patient takes offense, explain that you ask all of your patients
these questions and that there is nothing specific about her that
is prompting you to screen.
Include a few basic questions on GBV in a general health-status
assessment, which is routinely provided to all patients prior to
entering the practitioner’s examination room.
How do I ensure
privacy for
examination?
Exclude all family members and friends during examination
process since this may bias the victim’s response.
Privacy is essential (see next pages for issues related to privacy
and screening)
How do I find
the
time for
examination
and
intervention?
Include GBV assessment questions as part of the medical
assessment and/or a general health status assessment
Ask follow-up questions on GBV/DV during the medical
examination (please refer to annex 2 History and Examination
form). Ensure that no partner, child, family member or other
patients are present during this time.
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Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
Refer the victim to community-based organizations, and other
resources for counseling, housing and other issues. , Give the
victim the Domestic Violence Hotline number available in your
area (please refer to annex10 Referral Networks)
34 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
Diagram for How to Approach Assessment for
GBV
I don’t know how to ask about GBV/DV. It is a personal issue, and I feel
uncomfortable intruding on the patient’s emotional privacy.
Explain to the patient the purpose of asking questions about GBV. This can be achieved by
universalizing the problem in order to provide a context that is less threatening.
State that questions are asked routinely to all patients because of the prevalence of GBV and
its potential to harm the victims.
It may be uncomfortable at first, but with practice it will become easier. It is important for your
patients’ health and safety that you screen for GBV/DV.
How do I manage
a patient if she
discloses GBV/DV?
Listen supportively and validate
your patient’s experience. You
may be the first or only person
that she tells about the abuse.
Provide necessary medical
treatment for the patient.
Discuss various existing support
services with the victim give her
a general safety plan (p 8, part
3), or refer her.
Make appropriate referrals
based on the patient’s needs:
o Community based
organizations
o Counseling
o Legal services
o Medical services
o Social services
35 Page
What if the patient is
being abused but either
denies the abuse or
refuses help?


You need to respect your patient’s choice of
whether to disclose abuse and/or to seek help.
Attempting to leave an abusive relationship is
frequently dangerous for a domestic violence victim.
There may be financial and housing risks
associated with leaving an abusive relationship and
emergency shelter may not be immediately
available.
Discuss risk factors of further abuse with the
patient. Inform her that women are at greater risk of
harm when incidents of GBV/DV increase in
frequency or intensity.
Let your patient know that you are available in the
future if she chooses to seek assistance for her
situation.
Document your concerns and treatment in the
patient’s medical record and make a notation to
follow-up at future visits.
Screen for medical and psychological indicators of
abuse during subsequent visits, and offer
feedback/suggestions to the patient in this regard.
Provide information pamphlets
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
Look beyond appearances of your patients and their partners
How do I know he is
an abuser if he
doesn’t look like one?
Is it possible that people with bad
tempers are not aggressive all the
time?_______________________
Note three reasons why an abuser
may not want to show his abusive
side to people other than the
victim.
1.
______________________________
2.
______________________________
3.
______________________________
If the abuse was that
bad, wouldn’t she
disclose the abuse and
end the relationship?
Is it possible that some women do
not have overt signs of abuse?
__________________________
Is it possible that the victim is
ashamed of the abuse?_________
Is it possible that the abuser would
threaten to harm the victim if she
disclosed the abuse?
___________________________
Is it possible that the victim fears
serious consequences of leaving
the abuser, such as retaliation,
physical harm, lack of financial
assistance or abandonment by
members of her community?
___________________________
__
An abuser has the potential to be a “nice guy” to many people and still
abuse his partner. A woman may not display obvious signs of abuse or she
may hide the evidence for fear of adverse consequences. This illustrates the
importance of routinely screening all patients for domestic violence.
Summary:
AVDR
A = Ask patients about abuse
V = Validate, acknowledge abuse is wrong, confirm patient’s worth
D = Document presenting symptoms and disclosures
R = Refer victims to specialists
36 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
Challenges Preventing Women
from Disclosing GBV/DV
Overview of Challenges that Prevent Women From Disclosing
Domestic Violence
An environment
that is not
conducive to
disclosure
Fear for
personal
safety and
pressure from
the victim’s
support
system
Lack of
selective
screening
Lack of privacy
from the
abuser or
family member
during
screening
Lack of privacy
for screening in
the waiting
room
Lack of
assessment
beyond
physical
injuries
Concern
about bringing
shame to her
family and
losing their
support
Concern
about being
ostracized by
her
community
37 Page
Fear of legal
authorities
Fear of the
police
Mother’s
fear of
having
children
removed
from her
care
Factors
complicating
the diagnosis of
GBV/DV
The victim
being unaware
that
nonphysical
abuse
constitutes
GBV/DV
The victim
believing that
abuse is an
acceptable part
of her culture or
marital life
The victim’s
substance
abuse inhibiting
disclosure
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
AN ENVIRONMENT THAT IS NOT CONDUCIVE TO
DISCLOSURE
Lack of
selective
screening
Approximately 92% of women who are physically abused do not
voluntarily disclose abuse to physicians and 57% do not disclose
the abuse to anyone.
Research indicates that the majority of female patients would
disclose domestic violence if asked directly about it.
By screening, the practitioner can reduce a victim’s feeling of
isolation and provide meaningful information about her right to be
free from abuse.
Lack of
privacy
from the
abuser or
family
member
during
screening
A member of the victim’s family (such as her mother), the abuser or
his family member (such as his mother or sister), frequently
accompanies the victim to her medical appointments. These family or
extended family members may contribute to an environment that
tolerates the abuse, complicating the victim’s ability to seek help. If
these people are present during the screening, it will decrease the
likelihood of disclosure. It is crucial to speak to each patient privately
in order to effectively screen her for domestic violence.
Lack of
privacy for
screening in
the waiting
room
A domestic violence victim is unlikely to disclose her abuse if she
feels uncomfortable or unsafe doing so. Privacy for screening is
essential.
Lack of
assessment
beyond
physical
injuries
The majority of your domestic violence patients may be seeking
medical care for reasons other than injuries related to abuse, such as
an annual visit or prenatal care.
In addition to physical violence, abuse can be emotional, verbal,
financial and sexual in nature.
38 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
FEAR FOR PERSONAL SAFETY AND PRESSURE FROM
THE VICTIM’S SUPPORT SYSTEM
Concern about bringing shame to
her
family and losing their support
There may be significant pressure from
immediate and extended family members,
preventing the woman from disclosing
abuse.
Some factors to consider when
screening a patient for abuse:
She may not know that her
mistreatment is abuse.
Reporting abuse may imply that the
woman has failed as a wife and
mother because her role is to keep the
family together at all costs.
The woman may fear shame and
abandonment for herself and her
family.
The woman may fear loss of
emotional and financial support if she
discloses the abuse or leaves the
abuser.
She may believe or be told not to
discuss private issues with outsiders.
She may not have told her family
about the abuse.
Family or extended family members
may be present at medical
appointments, inhibiting the process of
disclosure.
Some family or extended family
members may condone and even
participate in the abuse.
A family’s misinterpretation of religious
text may sanction abuse.
Concern about being ostracized by
her community
Community pressure may play a significant
role in the patient’s decision not to disclose
abuse. Victims may be frightened or
ashamed about their community’s reaction
to their domestic violence situation. Many
women go to medical providers who have
been recommended by members of their
community. Also, certain doctors or facilities
predominantly serve certain communities.
Some factors to consider when screening
a patient for abuse:
Community members may deny the
prevalence of domestic violence.
She may fear bringing shame to her
community.
A previous medical provider from the
victim’s community may have
discouraged her from reporting the
abuse.
In certain cultures, family and community
reputation is perceived as being more
important than an individual’s needs.
She may not disclose the abuse for fear
of losing her support system (her family
and friends).
She may fear being abandoned by
members of her larger community if she
leaves her partner.
WHAT YOU CAN DO
Screen the patient for GBV/DV in private and try not allowing family members to attend
the interview.
Emphasize to the patient that you will respect her right to confidentiality.
Communicate effectively with patients from different populations as well as exploring
various options of treatment with them. Explain legal options and rights and required
procedures to protect and preserve these rights.
In case of disclosing GBV, going through the steps of examination, documentation,
reporting ..etc.
Provide the Violence against women Hotline number and referral information to the
patient, both within and outside of her community, depending on her preference.
39 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
FACTORS COMPLICATING THE DIAGNOSIS OF
GBV/DV
The victim being
unaware of
nonphysical
abuse
Many GBV/DV victims do not realize that they are in abusive
relationships, particularly in the absence of serious physical injuries.
What you can do
Briefly inform the patient about non-physical forms of
domestic violence.
Validate the victim’s experience by reassuring her that her
feelings and reactions are understandable.
The victim
believing abuse
to be an
acceptable part
of her culture or
marital life
Many women believe that being a victim of GBV/DV is a normal
part of their culture or marital life.
What you can do
Explain to the victim that GBV/DV is a global problem that
affects people from all cultures.
Emphasize that no one deserves to be abused, irrespective of
his/her culture.
Tell the victim that GBV/DV is against the law in Egypt.
The victim, who
is sexually
assaulted in her
relationship, is
unlikely to seek
medical attention
Forced sex is an independent risk factor for femicide. Research
indicates that many women are raped within the context of their
family life. There is a correlation between domestic violence
and forced sexual activity. In general, women who are assaulted
by a known perpetrator are less likely to seek assistance than
those assaulted by a stranger.
What you can do
Many victims do not disclose sexual assault either because
of shame or because they perceive this to be part of the
general abusive situation. Therefore, if GBV/DV is
identified, assess the patient for sexual assault and
vice versa.
The victim’s use
of
substances
making
it less likely to
seek
assistance
After the first incident of GBV/DV, victims are nine times more likely
to abuse drugs than non-battered women. This may be explained
as self-medicating;a method of coping with the trauma of being
abused.“Many women experiencing both domestic violence and
substance abuse feel that they have few places to turn where their
co-occurring problems are recognized, understood and dealt with
compassionately.”
What you can do
Assess for GBV/DV when working with patients who have a
substance abuse problem and vice versa.
41 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter two – Guideline Principles for Management of GBV
Ensure that both domestic violence and substance
abuse are addressed in an integrated treatment
program for the patient.
Summary
The practitioner should create an environment that is
conducive to disclosure.
Implement selective screening for GBV.
Ensure privacy for screening patients.
Ensure that neither the abuser nor a family member is
with the patient during the screening.
Pressure from the victim’s social system may negatively
impact disclosure.
Concern about bringing shame to her family and losing
their support may inhibit the victim’s disclosure of
domestic violence.
Some family members may condone and even
participate in the abuse.
Concern about being ostracized by her community may
inhibit disclosure.
Victims may fear legal authorities such as the police .
Victims may fear having their children removed from
their care.
Assess your patients for all types of abuse rather than
just treating physical injuries.
If appropriate, inform the patient about non-physical
types of abuse.
Inform the patient that abuse is unacceptable and
against the law.
Refer the victim to appropriate resources, both within
and outside her community, depending on her
preference.
41 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
Provider’s Guide for Management of Domestic Violence DV
Contents

Guidelines step by step

Tactics of control and clinical cues

When to consider domestic violence even if the patient does not disclose
abuse

Sample Screening Tool for Suspected Cases

Danger assessment instrument

Safety plan

Medical history and examination form
42 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
Guidelines and Tools
for Assessment and Management of DV
The following guidelines are designed to assist medical personnel in treating victims of
domestic violence (DV).
1. Interview the patient in private. Ask any accompanying spouse, friend or family member to
leave the treatment area. Questioning the patient about domestic violence in the presence of
the abuser, suspected abuser or other family members may put the patient in extreme danger.
2. Convey an attitude of concern and respect for the patient and assure the confidentiality of
any information provided. Provide psychological first aid (please refer to annex 3
Psychological First Aid)
3. Explain to the patient why you are asking about domestic violence and ask the patient
directly if the injuries or complaints are the result of abuse by someone they know.
4. If domestic violence is disclosed, communicate to the victim that they are not alone, they
are not to blame for the abuse, and that help is available.
5. Take the patient’s history and conduct a thorough medical examination, with appropriate
laboratory tests and x-rays. If the extent or type of injury is not consistent with the explanation
the patient gives, note this in the medical record. A question to elicit information about site and
cause of injury that might indicate domestic violence should be asked. Ask for specifics and
document using the patient’s own words. Keep results in confidential history and examination
form (Annex 2 History and Examination form) and GBV log book18.
Examples:
“She threw a cup of coffee at me” is better than “We were arguing and things got out of hand.”
“Patient states that her husband, Adel Ibrahim, hit her with his belt” is better than “Patient has
been abused.”
All emergency department logs should include a code for domestic violence.
6. Ask victim to preserve physical evidence such as blood stained clothing and/or weapon. It
is recommended to apply the following: Mark forensic paper bag with patient’s name, date and
name of person who collected evidence. Keep evidence under lock until it is turned over to
the police, or forensic medicine.
N.B. MOHP health service providers trained on Sexual Assault Forensic Examiner (SAFE)
conducted by Forensic Medicine Department at Ministry of Justice are illegible to collect
forensic evidence as per the recommendations of the High Committee (including Ministry of
18
GBV Log Book: anonymous based on serial numbering with the aim of tracking of GBV cases, referral
and services provided. GBV log book to be integrated in registry system of the hospitals as per the
recommendations of the High Committee developing the GBV Medical Protocol and validated by the
Ministry of Health and Population in Egypt - MOHP
43 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
Justice Representatives) which developed the GBV Medical Protocol validated by the
Ministry of Health and Population in Egypt – MOHP
7. Help the victim assess their immediate safety and safety of the children. Respect and accept
the victim’s evaluation of the situation. Offer your patient safety assessment and safety plans.
If appropriate, offer to call the police. Tell the patient that battering is a crime and help is
available. Support the patient’s decision.
8. Encourage the patient to call a local domestic violence program or Domestic Violence
Hotline (08008883888 NCW19 – 01126977222 MOI20 - 01126977333 - 01126977444).
Ensure access to a private telephone.
9. Provide additional information and referrals for counseling, shelter, support groups and legal
assistance in the community. Assure confidentiality (please refer to annex 10 Referral
Networks).
10. Make safety the primary goal of all interventions. Victims are likely to be the best judge of
what is safe for them. If it is necessary to follow-up with medical appointments, laboratory tests
or prescriptions, ask directly if the victim can safely do so, or what could be done to make it
possible for her to meet follow-up care needs.
11. Medical care of a victim of sexual assault include preparing a medical certificate. This is a
main requirement to pursue further legal processes.21 (please refer to annex 4 Medical
certificate and guideline)
12. Mandatory reporting to police when the nature of injury indicate criminal act as per the
Egyptian procedural criminal law article 25, 26 on mandatory reporting by civil servants (please
refer to annex 1)
Tactics & Clinical Cues
Tactics of control may manifest in the following ways:
Tactics
Health Care Manifestations
Physical Abuse
• Biting
• Grabbing
• Punching
• Shoving
• Kicking
• Slapping
• Shooting
19
20
21
• Ecchymosis (bruises)
• Lacerations, often to arms & face
• Headaches
• Anxiety
• Hyperventilation
• Hypertension
• Chest pains
National Council for Women
Ministry of interior – Violence against women unit
Step 11 and 12 may alternate in order depending on the victim’s first attempts to seek help
44 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
• Stabbing, etc.
• Withholding medication, medical care,
medical equipment, nutrition
• Forcing use of alcohol or other drugs
 Traditional practices : Female genital
cutting (female circumcision)
• Chronic pain
• During pregnancy
− Injury to abdomen, breasts, genitalia
− Hemorrhaging, including placental
separation
− Uterine rupture
− Miscarriage/stillbirth
− Pre-term labor
− Premature rupture of membranes
• Delay in seeking prenatal care
• Frequently missed appointments
• Lack of attendance to prenatal education
• Poor nutrition
• Continued use of cigarettes, drugs and/or
alcohol during pregnancy
Psychological Abuse
• Instilling, or attempting to instill fear
through ridiculing or humiliating the victim
• Destroying property
• Threatening to harm self or victim
• Blaming abuse on victim
• Injuring, killing, or threatening to injure or
kill pets
• Depression
• Anxiety
• Hypertension
• Chronic muscle tension
• Psychosomatic illness
• Suicidal ideation
• Homicidal ideation
• Substance abuse
Sexual Abuse
• Coercing, or attempting to coerce any
sexual activity without consent
− Rape, sodomy, attacks on sexual parts of
the body
− Unprotected sex
− Sex with others
− Forced prostitution
− Degrading, sexually explicit behavior
toward victim
− Taking/showing sexually explicit film or
photos and using them against the victim
• Attempts to undermine a person’s
sexuality
− Treating partner in a sexually derogatory
manner
− Criticizing sexual performance and
desirability
− Accusations of infidelity
− Withholding sex
45 Page
• STD’s
• HIV
• Multiple pregnancies
• Pregnancy-related injuries, usually around
abdomen, breast and genitalia
• Spontaneous abortion
• Sexual assault injuries
• Depression
• Anxiety
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
Economic Abuse
• Making, or attempting to make a person
financially dependent
• Depression
• Anxiety
• Migraines/headaches
• Reluctance to schedule additional tests, or
accept needed prescriptions
Emotional Abuse
• Undermining, or attempting to undermine, • Depression
a person’s self-worth
• Anxiety
− Constant criticism
• Hypertension
− Put downs
• Chronic muscle tension
− Insults
• Substance abuse
− Name calling
• Suicidal ideation
− Silent treatment
• Homicidal ideations
− Manipulating feelings/emotions
• Psychosomatic illness
− Repeatedly making and breaking
promises
− Subverting partner’s parenting and/or
relationship with children
***NOTE: Any pre-existing conditions can be
− Threatening to harm, kill or abduct
exacerbated by domestic violence
children
− Using child visitation to harass victim
If the patient does not disclose abuse, consider domestic violence if any of the
following is observed:
• Injuries to face, neck, throat, chest, abdomen or genitals
• Evidence of sexual assault; vaginal/anal injuries
• Bilateral or patterned injuries
• Injuries during pregnancy
• Delay between injury and treatment
• Multiple injuries in various stages of healing
• Injury inconsistent with patient’s explanation
• Frequent use of emergency department services
• History of trauma related injury
• Chronic pain symptoms with no apparent etiology
• Repeated psychosomatic or emotional complaints
• Suicidal ideation or attempts
• An overly attentive or aggressive partner accompanying the patient
• Patient appears fearful of partner
Types of cases of mandatory reporting:
To be completed with forensic
46 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
Sample Screening Tool for Suspected Cases
(This screening tool is to be administered as an interview)
“Because many people experience violence by someone close to them, you have to
ask your patients the following questions. We believe that no one should suffer from
abuse. There are things that healthcare providers can do to help people who are
being abused.”
Yes
No
1. Do you feel unsafe with anyone who lives with you or routinely stays in
your home?
2. Within the past year, has someone close to you:
a) Hit, slapped, kicked, pushed or otherwise physically hurt you?
b) Controlled your actions such as whom you see, whom you talk to,
where you go or what you wear?
c) Forced you to do something you don’t want to do?
d) Controlled your access to all finances?
e) Prevented you from having access to your personal and legal
documents?
f) Threatened you?
g) Intimidated you?
h) Isolated you from friends and family?
i) Constantly criticized you, called you names, or put you down?
If yes, what is the relationship of that person to you?
3. Within the past year, has anyone forced you to have unwanted sexual
activity?
If yes, what is the relationship of that person to you?
4. Are you afraid of your husband, previous husband or anyone who may be
living in your home?
If the person answers “yes” to question 1,2,3 or 4, ask:
5. Would you like:
a) To discuss your situation with someone who has expertise in
these matters?
b) Additional information on domestic violence?
Comments:
___________________________________________________________________
___________________________________________________________________
Referrals made to: (Center)
___________________________________________________________________
Follow-up plan:
___________________________________________________________________
Completed by: _____________________
47 Page
Date: ___________________
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
Sample History and Examination form22
(Victims of domestic and sexual violence)
CONFIDENTIAL
1.
CODE:
GENERAL INFORMATION
First Name
Last Name
Address
Sex
Date of birth
Date / time of examination
Age
/
In the presence of
In case of a child include: name of school, name of parents or guardian
2.
THE INCIDENT
Date of incident:
Time of incident:
Description of incident (survivor’s description)
Physical violence
Yes
No
Describe type and location on body
Yes
No
Not sure
No
Not sure
Type (beating, biting, pulling
hair, etc.)
Use of restraints
Use of weapon(s)
Drugs/alcohol involved
Penetration
Describe (oral, vaginal, anal, type of
object)
Penis
Finger
Other (describe)
Yes
Location (oral, vaginal, anal, other).
Ejaculation
Condom used
22
Annex 2
48 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
If the survivor is a child, also ask: Has this happened before? When was the first time?
How long has it been happening? Who did it? Is the person still a threat? Also ask about
bleeding from the vagina or the rectum, pain on walking, dysuria, pain on passing stool,
signs of discharge, any other sign or symptom.
3.
MEDICAL HISTORY
After the incident, did the survivor
Yes
No
Yes
Vomit?
Rinse mouth?
Urinate?
Change clothing?
Defecate?
Wash or bathe
Brush teeth?
Use tampon or pad
No
Contraception use
Pill
IUD
Sterilization
Injectable
Condom
Other
Menstrual/obstetric history
Last menstrual period
Menstruation at time of event
Evidence of pregnancy
Yes  No 
Yes  No 
Number of weeks pregnant
_____ weeks
Obstetric history
History of consenting intercourse (only if samples have been taken for DNA analysis)
Last consenting intercourse within a week prior to the assault
Name of individual:
Date:
Existing health problems
History of female genital mutilation, type
Allergies Current medication
Vaccination status
Vaccinated
Not vaccinated
Unknown
Comments
Tetanus
Hepatitis B
HIV/AIDS status
49 Page
Know
Unknown
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
4. Medical examination
Appearance (clothing, hair, obvious physical or mental disability)
Mental state (calm, crying, anxious, cooperative, depressed, other)
Weight:
Height:
Pubertal stage (pre-pubertal, pubertal, mature):
Pulse rate:
Blood pressure:
Respiratory rate:
Temperature:
Physical findings
Describe systematically, and draw on the attached body pictograms, the exact location of all
wounds, bruises, petechiae, marks, etc. Document type, size, colour, form and other particulars.
Be descriptive, do not interpret the findings.
Head and face
Mouth and nose
Eyes and ears
Neck
Chest
Back
Abdomen
Buttocks
Arms and hands
Legs and feet
5. GENITAL AND ANAL EXAMINATION
Vulva/scrotum
Introitus and hymen
Vagina/penis
Cervix
Anus
Bimanual/recto-vaginal
examination
Position of patient (supine, prone, knee-chest, lateral, mother’s lap)
For genital examination:
51 Page
For anal examination:
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
6. INVESTIGATIONS DONE
Type and location
Examined/sent to laboratory
Result
Sent to…/stored
Collected by/date
7. EVIDENCE TAKEN
Type and location
8. TREATMENTS PRESCRIBED
Treatment
Yes
No
Type and Comments
STI prevention/treatment
Emergency contraception
Wound treatment
Tetanus prophylaxis
Hepatitis B vaccination
Post-exposure prophylaxis for HIV
Other
9. COUNSELLING, REFERRALS, FOLLOW-UP
General psychological status
Survivor plans to report to police OR has already made report
Survivor has a safe place to go
Yes

No 
Yes

No 
Has someone to accompany her/him

Yes
 No
Counselling provided:
Referrals
Follow-up required
Date of next visit
Name of health worker conducting examination/interview: ___________________
Title: _______________ Signature: ____________________ Date: _____________
51 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
DANGER ASSESSMENT INSTRUMENT
This instrument could be used by health provider or victim
Several risk factors have been associated with homicides of battered women and their
batterers in research conducted after the murders occurred. We cannot predict what
will happen in your case, but we would like you to be aware of the homicide risk in
situations of severe battering. Please answer the questions below to see how many of
the homicide risk factors apply to your situation.
Please mark Yes or No for each of the following. (“He” refers to your husband,
partner, ex-husband, or whoever is currently physically hurting you).
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
19
52 Page
Has the violence increased in frequency over the past year?
Has he ever used a weapon against you or threatened you with a
weapon?
Does he ever try to choke you?
Does he own a gun?
Has he ever forced you to have sex when you did not wish to do
so?
Does he use drugs? By drugs, I mean happiness pills or Tramadol,
sleeping pills, powders , “hashish ”, street drugs or mixtures.
Does he threaten to kill you and/or do you believe he is capable of
killing you?
Is he drunk every day or almost every day?
Does he control most or all of your daily activities? For instance:
does he
tell you who you can be friends with, how much money you can
take with
you shopping, or when you can take the car? (If he tries, but you
do not
let him, check here: ________)
Have you ever been beaten by him when you were pregnant? (If
you have never been pregnant by him, check here: _______)
Is he violently and consistently jealous of you? (For instance, does
he
say, “If I can’t have you, no one can.”)
Have you ever threatened or tried to commit suicide?
Has he ever threatened or tried to commit suicide?
Does he threaten to harm your children?
Do you have a child that is not his?
Is he unemployed?
Have you left him during the past year? (If you never lived with
him, check here:_______)
Does he follow or spy on you, leave threatening notes, destroy
your property, or call you when you don’t want him to?
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
No
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
SAFETY PLAN
� Call 122 or 01126977222- 01126977333 ( MOI VAW unit) if you are in
danger or have been hurt by your husband or whoever is physically hurting
you. .
� Have a neighbor or friend call 122 on your behalf if they hear suspicious
noises coming from
your home.
� Teach your children to use the telephone to call the police.
� Teach your children to go to a safe place during a violent incident, for
example, their bedroom or a neighbor’s house.
� Gather important documents, including:
__ National ID or Passports (for you and your children)
__ Work permit
__ Marriage and birth certificates
__ Children's immunization and school records
__ Driver’s license
__ Bank account details
__ Medical insurance card
� Keep these documents in a safe and immediately accessible place.
� Gather sentimental photographs (including photographs of the abuser) and
other personal
items.
� Hide some money, a checkbook, ATM card, spare keys, medications and a
bag packed with
necessities for you and your children.
� Identify a place to stay in case of an emergency.
� Know the location of your local police precinct.
� Memorize the number of a domestic violence agencies. The number for the
Domestic Violence Hotline/s (please refer to annex 10 Referral Networks).
� Document your abuse. ; get copies of medical and police reports, .
� Obtain an Order of Protection (according to local legislations )and give a
copy to your local police precinct and children’s
school or childcare provider.
53 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
‫تقرير اصابي ابتدائي‬
(please refer to annex 4)
54 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter three – Provider’s Guide for Management of Domestic Violence
55 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
Provider's guide for clinical management of
rape/sexual violence
Contents

Introduction

Preparations required to offer appropriate medical care to victims of rape

Steps to deal with a sexually abused person
o STEP 1 – Preparing the victim for the examination
o STEP 2 – Taking the history
o STEP 3 – Collecting forensic evidence
o STEP 4 – Performing the physical and genital examination
o STEP 5 – Prescribing treatment
o STEP 6 – Counseling the patient
o STEP 7 - Follow-up care of the survivor

Care of child survivor
The essential components of medical care after a rape or sexual assault are:
 Documentation of injuries,

Collection of forensic evidence,

Treatment of injuries,

Evaluation for sexually transmitted infections (STIs) and preventive care,

Evaluation for risk of pregnancy and prevention,

Psychosocial support, counseling and follow-up.

Referral and reporting to legal authorities
56 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
Introduction
Rape or sexual assault is a traumatic experience, both emotionally and physically. Survivors
may have been raped by a number of people in a number of different situations; they may
have been raped by strangers, friends, , fathers, uncles or other family members; they may
have been raped while working in field, using the latrine, in their beds or visiting friends.
"They may have been raped by one, two, three or more people, by men or boys, or by women.
They may have been raped once or a number of times over a period of months. Survivors may
be women or men, girls or boys; but they are most often women and girls, and the perpetrators
are most often men.
Survivors may react in any number of ways to such a trauma; whether their trauma reaction
is long-lasting or not depends, in part, on how they are treated when they seek help. By
seeking medical treatment, survivors are acknowledging that physical and/or emotional
damage has occurred. They most likely have health concerns. The health care provider can
address these concerns and help survivors begin the recovery process by providing
compassionate, thorough and high-quality medical care, by centering this care around the
survivor and her needs, and by being aware of the setting-specific circumstances that may
affect the care provided".23
Rape is considered the most severe form of sexual violence. It is a public health problem and
a human rights violation. All individuals, including actual and potential victims of sexual
violence, are entitled to the protection of, and respect for, their human rights, such as the right
to life, liberty and security of the person, the right to be free from torture and inhuman, cruel
or degrading treatment, and the right to health. Governments have a legal obligation to take
all appropriate measures to prevent sexual violence and to ensure that quality health services
equipped to respond to sexual violence are available and accessible to all. Health care
providers should respect the human rights of people who have been raped.
What are preparations required to offer appropriate medical care to
victims of rape?
The health care service must make preparations to respond thoroughly and compassionately
to people who have been raped/sexually abused. The health system/institution should ensure
that health care providers (doctors, medical assist, nurses, etc.) are trained to provide
appropriate care and have the necessary equipment and supplies. Female health care
23
Health and Gender Equity (CHANGE)
57 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
providers should be trained as a priority, but a lack of trained female health workers should
not prevent the health service providing care for survivors of rape/sexual violence.
In setting up a service, the following questions and issues need to be addressed, and standard
procedures developed.
What should the community be aware of? (awareness raising at all levels)
Members of the community should know:

what services are available for people who have been raped/sexually abused;

why rape survivors would benefit from seeking medical care;

where to go for services;

that rape survivors should come for care immediately or as soon as possible after the
incident, without bathing or changing clothes;

that rape survivors can trust the service provider to treat them with dignity, maintain their
security, and respect their privacy and confidentiality;

when services are available; this should preferably be 24 hours a day,7 days a week.
What are the country's laws and policies?





Legal and security safeguards in Egypt against Gender based violence (please refer
to chapter one“Overview and basic information about Gender-Based Violence
(including sexual violence)” page 21)
According to this GBV medical protocol, the health service provider should provide the
victim with the comprehensive care as detailed in chapter 2 “Guiding Principles for
Management of GBV”.
If the person wishes to report the rape/sexual abuse officially to the authorities,
according to the Egyptian laws and procedures, the health service provider examining
the victim at the public hospital should provide the victim with the official medical
certificate and keep the forensic evidence locked in a secure place until handed to the
relevant authorities.
If the service provider recognizes symptoms of rape/sexual abuse whether disclosed
or not, he/she is required by law to report the case to legal authorities. Nonetheless
the victim retain the right to confirm or deny without affecting her right in obtaining
health services and without any liability on the service provider (please refer to annex
1: service providers' right of reporting and cases of mandatory reporting)
What are the legal requirements with regard to forensic evidence?
In Egypt, collecting forensic evidence is the responsibility of the forensic medicine
department pertaining to the Ministry of Justice. The step of collection of forensic
evidence only takes place after the case has been referred to prosecution. The normal
path to prosecution takes several days risking the loss of evidence. Efforts to expedite
the process cannot be guaranteed, as forensic medicine specialists are few to be able
to respond to on call requests to sites in 27 governorates of Egypt. Therefore, it has
been recommended by the High Committee developing the GBV Medical Protocol
(validated by the Ministry of Health and Population in Egypt – MOHP and the Ministry
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Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
of Justice) that trained MOHP health service providers on Sexual Assault Forensic
Examiner (SAFE) (please refer to annex 5 ) training can resume the preliminary role
of forensic evidence collection.

What are the national laws regarding management of the possible medical
consequences of rape (e.g. emergency contraception, abortion, testing and
prevention of human immunodeficiency virus (HIV) infection)?
The Egyptian laws do not legalize abortion (despite the existence of approving Fatwa
of abortion in case of rape). Emergency contraception and providing prophylaxis
against STDs and HIV are part of this protocol and can be provided by the health
service provider if identified as needed (please refer to annexes 7, 8 & 9)
Testing for HIV/AIDS is not mandatory by law; it is voluntary and needs victim
consent.
What resources and capacities are available?

Laboratory facilities for forensic testing (DNA analysis, acid phosphatase) are only
available at the forensic medicine laboratories. HIV testing is only available at the
central laboratory of MOHP, VCT centers, blood banks and some private labs.

Counseling guidelines are available in the GBV management training package.
Psychological first aid is available (Please refer to annex 3 ) and advanced
psychological counseling would be provided by a specialist at a referral point.(please
refer to annex 10 Referral Networks)

National STI treatment protocol, a post-exposure prophylaxis (PEP) protocol and
vaccines for hepatitis B and Tetanus are available but not across all levels of health
care.

Referral of victim of GBV to a secondary health care facility (counseling services,
surgery, pediatrics, or gynecology/obstetrics services) or additional psycho-social,
protection and legal support services should be made available in hospitals as per this
protocol.
Where should care be provided? (Please refer to chapter 2 “Guiding Principles for
Management of GBV”)
Generally, a clinic or outpatient service that already offers reproductive health services, such
as antenatal care, normal delivery care, or management of STIs, can offer care for rape/sexual
abuse survivors. Also emergency room at all selected hospitals should provide the service in
case of referral to a hospital.
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Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
Who should provide care? (Please refer to chapter 2 page 2 “Roles and Responsibility of
Health Care Provider Matrix”)
All staff in health facilities dealing with rape/sexual abuse survivors, from reception staff to
health care professionals, should be sensitized and trained. They should always be
compassionate and respect confidentiality.
How should care be provided?
Care should be provided:

according to a protocol that has been specifically developed for the situation. Protocols
should include guidance on medical, psychosocial and ethical aspects, on collection
and preservation of forensic evidence, and on referral to other more specialized
protection (shelters), legal and social services; and on counseling/ psychological
support options;

in a compassionate and non-judgmental manner;

with a focus on the survivor and her needs;

with an understanding of the provider's own attitudes and sensitivities, the sociocultural context, and the community's perspectives, practices and beliefs.
What is needed?

All health care for rape/sexual abuse survivors should be provided in one place within
the health care facility so that the person does not have to move from place to place.

Services should be available 24 hours a day, 7 days a week.

All available supplies from the checklist below should be prepared and kept in a special
box or place, so that they are readily available.

One trained health care provider on sexual assault forensic evidence collection
How to coordinate with others

Interagency and inter-sectoral coordination should be established to ensure
comprehensive care for survivors of sexual violence.

Be sure to include representatives of social and community services, protection, the
police or legal justice system, and security. Depending on the services available in the
particular setting, others may need to be included.

As a multi-sectoral team, establish referral networks, communication systems,
coordination mechanisms, and follow-up strategies. (Recommendations to MOHP
system change)
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Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
Checklist of needs for clinical management of rape survivors
1 Protocol
Available
 Written medical protocol in language of provider*
2 Personnel
Available
 Trained (local) health care professionals (on call 24 hours/day)*
 For female survivors, a female health care provider speaking the same
language is optimal. If this is not possible, a female health worker/social
worker (or companion) should be in the room during the examination*
3 Furniture/Setting
Available
 Room (private, quiet, accessible, with access to a toilet or latrine)*
 Examination table*
 Light, preferably fixed (a torch may be threatening for children)*
 Magnifying glass (or colposcope)
 Access to an autoclave to sterilize equipment*
 Access to laboratory facilities/microscope/trained technician
 Weighing scales and height chart for children
4 Supplies Available
 “Rape Kit” for collection of forensic evidence, could include:
 Speculum* (preferably plastic, disposable, only adult sizes)
 Comb for collecting foreign matter in pubic hair
 Syringes/needles (butterfly for children)/tubes for collecting
blood
 Glass slides for preparing wet and/or dry mounts (for sperm)
 Cotton-tipped swabs/applicators/gauze compresses for
collecting samples
 Laboratory containers for transporting swabs
 Paper sheet for collecting debris as the survivor undresses
 Tape measure for measuring the size of bruises, lacerations,
etc*.
 Paper bags for collection of evidence*
 Paper tape for sealing and labeling containers/bags*
 Supplies for universal precautions (gloves, box for safe disposal of
contaminated and sharp materials, soap)*
 Resuscitation equipment*
 Sterile medical instruments (kit) for repair of tears, and suture material
61 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
 Needles, syringes*
 Cover (gown, cloth, sheet) to cover the survivor during the examination*
 Spare items of clothing to replace those that are torn or taken for
evidence
 Sanitary supplies (pads or local cloths)*
 Pregnancy tests
 Pregnancy calculator disk to determine the age of a pregnancy
Available
5 Drugs
 For treatment of STIs as per country protocol*
 For post-exposure prophylaxis of HIV transmission (PEP)
 Emergency contraceptive pills and/or copper-bearing intrauterine
device (IUD)*
 Tetanus toxoid, tetanus immuno-globulin
 Hepatitis B vaccine
 For pain relief* (e.g. paracetamol)
 Anxiolytic (e.g. diazepam)
 Sedative for children (e.g. diazepam)
 Local anaesthetic for suturing*
 Antibiotics for wound care*
6 Administrative Supplies






Available
Medical chart with pictograms*
Forms for recording post-rape care
Consent forms*
Information pamphlets for post-rape care (for survivor)*
Safe, locked filing space to keep records confidential*
Other medical documentation form (log book, Hist.&Exam. form……etc)
Items marked with an asterisk * are the minimum requirements for examination and treatment
of a rape survivor.
62 Page
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
Steps to deal with a sexually abused person
STEP 1 – Preparing the victim for the examination
A person who has been raped/sexually abused has experienced trauma and may be
in an agitated or depressed state. She often feels fear, guilt, shame and anger, or any
combination of these. The health provider must prepare her and obtain her informed
consent for the examination, and carry out the examination in a compassionate,
systematic and complete fashion.
To prepare the victim for the examination:
 Introduce your-self.
 Ensure that a trained health worker of the same sex accompanies the victim
throughout the examination.
 Explain what is going to happen during each step of the examination, why it is
important, what it will tell you, and how it will influence the care you are going to
give.
 Reassure the victim that she is in control of the pace, timing and components of
the examination.
 Reassure her that the examination findings will be kept confidential unless she
decides to bring charges (please refer to annex 6 consent form).
 Ask her if she has any questions.
 Ask if she wants to have a specific person present for support. Try to ask her this
when she is alone.
 Review the consent form (please refer to annex 6 consent form) with her. Make
sure she understands everything in it, and explain that she can refuse any aspect
of the examination she does not wish to undergo. Explain to her that she can delete
references to these aspects on the consent form. Once you are sure she
understands the form completely, ask her to sign it. If she cannot write, obtain a
thumb print together with the signature of a witness.
 Limit the number of people allowed in the room during the examination to the
minimum necessary.
 Do the examination as soon as possible.
 Do not force or pressure her to do anything against her will. Explain that she can
refuse steps of the examination at any time as it progresses.
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Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
STEP 2 – Taking the history
General guidelines
 If the interview is conducted in the treatment room, cover the medical instruments
until they are needed.
 Before taking the history, review any documents or paperwork brought by the victim
to the health centre.
 Use a calm tone of voice and maintain eye contact if culturally appropriate.
 Let the victim tell her story the way she wants to.
 Questioning should be done gently and at the victim's own pace. Avoid questions
that suggest blame, such as "what were you doing there alone?"
 Take sufficient time to collect all needed information, without rushing.
 Do not ask questions that have already been asked and documented by other
people involved in the case.
 Avoid any distraction or interruption during the history-taking.
 Explain what you are going to do at every step.
 Prepare for bringing on-board a female nurse or service provider during physical
examination (advisable to be present at all times during examination).A female
physician to perform the physical examination is recommended.
 A sample history and examination form is included in Annex 5. The main elements
of the relevant history are described below.
General information
 Name, address, sex, date of birth (or age in years).
 Date and time of the examination and the names and function of any staff or
support person (someone the survivor may request) present during the interview
and examination.
Description of the incident
 Ask the victim to describe what happened. Allow her to speak at her own pace. Do
not interrupt to ask for details; follow up with clarification questions after she
finishes telling her story. Explain that she does not have to tell you anything she
does not feel comfortable with.
 Victims may omit or avoid describing details of the assault that are particularly
painful or traumatic, but it is important that the health provider understands exactly
what happened in order to check for possible injuries and to assess the risk of
pregnancy and STI or HIV. Explain this to her , and reassure her of confidentiality
if she is reluctant to give detailed information. The form in Annex 5 specifies the
details needed.
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Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
History
 If the incident occurred recently, determine whether the victim has bathed,
urinated, defecated, vomited, used a vaginal douche or changed her clothes since
the incident. This may affect what forensic evidence can be collected.
 Information on existing health problems, allergies, use of medication, and
vaccination and HIV status will help you to determine the most appropriate
treatment to provide, necessary counseling, and follow-up health care.
 Evaluate for possible pregnancy; ask for details of contraceptive use and date of
last menstrual period.
In developed country settings, some 2% of survivors of rape have been found to be
pregnant at the time of the rape. Some were not aware of their pregnancy. Explore the
possibility of a pre-existing pregnancy in women of reproductive age by a pregnancy
test or by history and examination. The following guide suggests useful questions to
ask the survivor if a pregnancy test is not possible.
A guide for confirming pre-existing pregnancy
No
Yes
1 Have you given birth in the past 4 weeks?
2 Are you less than 6 months postpartum and fully breastfeeding
and free from menstrual bleeding since you had your child?
3 Did your last menstrual period start within the past 10 days?
4 Have you had a miscarriage or abortion in the past 10 days?
5 Have you gone without sexual intercourse since your
last menstrual period (apart from the incident)?
6 Have you been using a reliable contraceptive method
consistently and correctly? (check with specific questions)
If the survivor answers NO to
all the questions, ask about
and look for signs and
symptoms of pregnancy. If
pregnancy cannot be
confirmed provide her with
information on emergency
contraception to help her
arrive at an informed choice
(see Step 7)
65 Page
If the survivor answers YES to
at least 1 question and she is
free of signs and symptoms of
pregnancy, provide her with
information on emergency
contraception to help her
arrive at an informed choice
(see Step 7)
Medical Protocol/Guidelines for Management of Victims of GBV (including sexual violence)
Chapter four – Provider's Guide for management of rape/sexual violence victims
STEP 3 – Collecting forensic evidence
The main purpose of the examination of a rape victim is to determine what medical care
should be provided. Forensic evidence may also be collected to help the survivor pursue
legal redress where this is possible. The survivor may choose not to have evidence
collected. Respect her choice.
In Egypt, collecting forensic evidence is the responsibility of the forensic medicine
department pertaining to the Ministry of Justice. The step of collection of forensic
evidence only takes place after the case has been referred to prosecution. The normal
path to prosecution takes several days risking the loss of evidence. Efforts to expedite
the process cannot be guaranteed, as forensic medicine specialists are few to be able
to respond to on call requests to sites in 27 governorates of Egypt. Therefore, it has
been recommended by the High Committee developing the GBV Medical Protocol
(validated by the Ministry of Health and Population in Egypt – MOHP and the Ministry
of Justice) that trained MOHP health service providers on Sexual Assault Forensic
Examiner (SAFE) (please refer to annex 5 ) training can resume the preliminary role
of forensic evidence collection.
-
Referral to other entities for collection of forensic evidence in case no trained service
provider is on duty at the time of receiving the case.
Reasons for collecting evidence
A forensic examination aims to collect evidence that may help prove or disprove a connection
between individuals and/or between individuals and objects or places. Forensic evidence may
be used to support a survivor's story, to confirm recent sexual contact, to show that force or
coercion was used, and possibly to identify the attacker. Proper collection and storage of
forensic evidence can be key to a survivor's success in pursuing legal redress. Careful
consideration should be given to the existing mechanisms of legal redress and the local
capacity to analyze specimens when determining whether or not to offer a forensic
examination to a survivor. The requirements and capacity of the local criminal justice system
and the capacity of local laboratories to analyze evidence should be considered (please refer
to annex 5)
Collect evidence as soon as possible after the incident
Documenting injuries and collecting samples, such as blood, hair, saliva and sperm, within 72
hours of the incident may help to support the survivor's story and might help identify the
aggressor(s). If the person presents more than 72 hours after the rape, the amount and type
of evidence that can be collected will depend on the situation. Whenever possible, forensic
evidence should be collected during the medical examination so that the survivor is not
required to undergo multiple examinations that are invasive and may be experienced as
traumatic.
Documenting the case (please refer to annexes 2 & 4)


Record the interview and your findings at the examination in a clear, complete, objective,
non-judgmental way.
It is not the health care provider's responsibility to determine whether or not a woman has
been raped. Document your findings without stating conclusions about the rape. Note that
in many cases of rape there are no clinical findings.
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

Completely assess and document the physical and emotional state of the survivor.
Document all injuries clearly and systematically, using standard terminology and
describing the characteristics of the wounds (see Table 1). Record your findings on
pictograms (please refer to annex 6). Health workers who have not been trained in injury
interpretation should limit their role to describing injuries in as much detail as possible (see
Table 1), without speculating about the cause, as this can have profound consequences
for the survivor and accused attacker.
Record precisely, in the survivor's own words, important statements made by her, such as
reports of threats made by the assailant. Do not be afraid to include the name of the
assailant, but use qualifying statements, such as "patient states" or "patient reports".
Avoid the use of the term "alleged", as it can be interpreted as meaning that the survivor
exaggerated or lied.
Make note of any sample collected as evidence.



Table 1: Describing features of physical injuries24
FEATURE
Classification
NOTES
Use accepted terminology wherever possible, i.e. abrasion, contusion,
laceration, incised wound, gunshot.
Site
Record the anatomical position of the wound(s).
Size
Measure the dimensions of the wound(s).
Shape
Describe the shape of the wound(s) (e.g. linear, curved, irregular).
Surrounds
Note the condition of the surrounding or nearby tissues (e.g. bruised,
swollen).
Observation of colour is particularly relevant when describing bruises.
Color
Course
Contents
Age
Borders
Depth
Comment on the apparent direction of the force applied (e.g. in
abrasions).
Note the presence of any foreign material in the wound (e.g. dirt, glass).
Comment on any evidence of healing. (Note that it is impossible
accurately to identify the age of an injury, and great caution is
required when commenting on this aspect.)
The characteristics of the edges of the wound(s) may provide a clue
as to the weapon used.
Give an indication of the depth of the wound(s); this may have to be
an estimate.
Samples that can be collected as evidence
Ideally, Forensic evidence should be collected during the medical examination and should be
stored in a confidential and secure manner. The consent of the survivor must be obtained
before evidence is collected .
24
Adapted from Guidelines for medico-legal care for victims of sexual violence, Geneva, WHO, 2003.
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The medical certificate/report (please refer to annex 4)
Medical care of a victim of rape/sexual violence includes preparing a medical certificate. This
is a legal requirement in most countries. It is the responsibility of the health care provider who
examines the victim to make sure such a certificate is completed. (please refer to annex 2,9)
The medical certificate is a confidential medical document that the doctor must hand over to
the survivor The medical certificate constitutes an element of proof and is often the only
material evidence available, apart from the survivor's own story. The health care provider
should keep one copy locked away with the survivor's file, in order to be able to certify the
authenticity of the document supplied by the survivor before a court, if requested.
The survivor has the sole right to decide whether and when to use this document.
The medical certificate may be handed over to legal services or to organizations with a
protection mandate only with the explicit agreement of the survivor.
N.B. The health service provider should register the GBV assault in the GBV Log Book:
anonymous based on serial numbering with the aim of tracking of GBV cases, referral and
services provided. GBV log book to be integrated in registry system of the hospitals as per the
recommendations of the High Committee developing the GBV Medical Protocol and validated
by the Ministry of Health and Population in Egypt - MOHP
If the service provider recognizes symptoms of rape/sexual abuse as stated below whether
disclosed or not, he/she is required by law to report the case to legal authorities.
Nonetheless the victim retain the right to confirm or deny without affecting her right in
obtaining health services and without any liability on the service provider (please refer to
annex
Types of cases of mandatory reporting:
To be completed with forensic







A medical certificate must include:
the name and signature of the examiner
and the registration number of the
psychian;*
the name of the survivor;*
the exact date and time of the
examination;*
the survivor's narrative of the rape, in her
own words;
the findings of the clinical examination;
the nature of the samples taken;
a conclusion.
* If the certificate is more than one page, these
elements should be included on every page of the
document.
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STEP 4 – Performing the physical and genital examination
The primary objective of the physical examination is to determine what
medical care should be provided to the victim.
What is included in the physical examination will depend on how soon after the rape the
survivor presents to the health service. Follow the steps in Part A if she presents within
72
hours of the incident; Part B is applicable to survivors who present more than 72 hours after
the incident. The general guidelines apply in both cases.
General guidelines

Make sure the equipment and supplies are prepared.

Always look at the survivor first, before you touch her, and note her appearance and
mental state ; some cases may need a specialist ; if available in your area call him/her.

Always tell her what you are going to do and ask her permission before you do it.

Assure her that she is in control, can ask questions, and can stop the examination at
any time.

Take the patient's vital signs (pulse, blood pressure, respiratory rate and temperature).

The initial assessment may reveal severe medical complications that need to be
treated urgently, and for which the patient will have to be admitted to hospital. Such
complications might include:
 extensive trauma (to genital region, head, chest or abdomen),
 asymmetric swelling of joints (septic arthritis),
 neurological deficits,
 respiratory distress.

The treatment of these complications is not covered here.

Obtain voluntary informed consent for the examination and to obtain the required
samples for forensic examination

Prepare for bringing on-board a female nurse or service provider during physical
examination

Record all your findings and observations as clearly and completely as possible on a
standard examination form (please refer to annex 5).
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Part A:
Victim presents within 72 hours of the incident
Physical examination

Never ask the survivor to undress or uncover completely. Examine the upper half of
her body first, then the lower half; or give her a gown to cover herself.

Minutely and systematically examine the patient's body. Start the examination with vital
signs and hands and wrists rather than the head, since this is more reassuring for the
victim. Do not forget to look in the eyes, nose, and mouth (inner aspects of lips, gums
and palate, in and behind the ears, and on the neck. Check for signs of pregnancy.
Take note of the pubertal stage.

Look for signs that are consistent with the victim's story, such as bite and punch marks,
marks of restraints on the wrists, patches of hair missing from the head, or torn
eardrums, which may be a result of being slapped. If the survivor reports being
throttled, look in the eyes for petechial haemorrhages. Examine the body area that was
in contact with the surface on which the rape occurred to see if there are injuries.

Note all your findings carefully on the examination form and the body figure pictograms
(please refer to annex 6), taking care to record the type, size, colour and form of any
bruises, lacerations, ecchymoses and petechiae.

Take note of the survivor's mental and emotional state (withdrawn, crying, calm, etc.).

Take samples of any foreign material on the survivor's body or clothes (blood, saliva,
and semen), fingernail cuttings or scrapings, swabs of bite marks, etc., according to
the local evidence collection protocol. (Function of forensic medicine in Egypt)
Examination of the genital area, anus and rectum
Even when female genitalia are examined immediately after a rape, there is identifiable
damage in less than 50% of cases. Carry out a genital examination as indicated below. Note
the location of any tears, abrasions and bruises on the pictogram and the examination form.

Systematically inspect, in the following order, the mons pubis, inside of the thighs,
perineum, anus, labia majora and minora, clitoris, urethra, introitus and hymen:
 Note any scars from previous female genital mutilation or childbirth.
 Look for genital injury, such as bruises, scratches, abrasions, tears (often
located on the posterior fourchette).
 Look for any sign of infection, such as ulcers, vaginal discharge or warts.
 Check for injuries to the introitus and hymen by holding the labia at the posterior
edge between index finger and thumb and gently pulling outwards and
downwards. Hymenal tears are more common in children and adolescents
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 Take samples according to your local evidence collection protocol. If
collecting samples for DNA analysis, take swabs from around the anus and
perineum before the vulva, in order to avoid contamination. (forensic medicine
function in Egypt )

For the anal examination the patient may have to be in a different position than for the
genital examination. Write down her position during each examination (supine, prone,
knee-chest or lateral recumbent for anal examination; supine for genital examination).
 Note the shape and dilatation of the anus. Note any fissures around the anus, the
presence of faecal matter on the perianal skin, and bleeding from rectal tears.
 If indicated by the history, collect samples from the rectum according to the local
evidence collection protocol. (Forensic medicine)
 If there has been vaginal penetration, gently insert a speculum, lubricated with
water or normal saline (do not use a speculum when examining children. (
postpone that step if referral to forensic is mandatory)
 Under good lighting inspect the cervix, then the posterior fornix and the vaginal
mucosa for trauma, bleeding and signs of infection.
 Take swabs and collect vaginal secretions according to the local evidence
collection protocol. .( postpone that step if referral to forensic is mandatory)

If indicated by the history and the rest of the examination, do a bimanual examination and
palpate the cervix, uterus and adnexa, looking for signs of abdominal trauma, pregnancy
or infection. ( referral to specialist)

If indicated, do a recto-vaginal examination and inspect the rectal area for trauma, rectovaginal tears or fistulas, bleeding and discharge. Note the sphincter tone. If there is
bleeding, pain or suspected presence of a foreign object, refer the patient to a hospital.(
referral to specialist)
N.B.: In Egyptian cultures, it is unacceptable to penetrate the vagina of a woman who is a
virgin with anything, including a speculum, finger or swab. In this case you may have to limit
the examination to inspection of the external genitalia, unless there are symptoms of
internal damage.
Laboratory testing (forensic medicine function and/or trained health service provider
on forensic evidence collection)
Only the samples mentioned in Step 4 need to be collected for laboratory testing. indicated by
the history or the findings on examination, further samples may be collected for medical
purposes. If the survivor has complaints that indicate a urinary tract infection, collect a urine
sample to test for erythrocytes and leukocytes, and possible for culture. Do a pregnancy test,
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if indicated and available. Other diagnostic tests, such as X-ray and ultrasound examination,
may be useful in diagnosing fractures and abdominal trauma.
Part B:
Victim presents more than 72 hours after the incident
Physical examination
It is rare to find any physical evidence more than one week after an assault. If the victim
presents within a week of the rape, or presents with complaints, do a full physical examination
as above. In all cases:

Note the size and colour of any bruises and scars;

note any evidence of possible complications of the rape (deafness, fractures,
abscesses, etc.);

check for signs of pregnancy;

note the survivor's mental state (normal, withdrawn, depressed, suicidal).
Examination of the genital area
If the assault occurred more than 72 hours but less than a week ago, note any healing injuries
to genitalia and/or recent scars. If the assault occurred more than a week ago and there are
no bruises or lacerations and no complaints (e.g. of vaginal or anal discharge or ulcers), there
is little indication to do a pelvic examination. Even when one might not expect to find injuries,
the survivor might feel that she has been injured. A careful inspection with subsequent
reassurance that no physical harm has been done may be of great relief and benefit to the
patient and might be the main reason she is seeking care.
Laboratory screening
Do a pregnancy test, if indicated and available (see Step 3). If laboratory facilities are
available, samples may be taken from the vagina and anus for STI screening for treatment
purposes.
Screening might cover:

rapid plasma reagin (RPR) test for syphilis or any point of care rapid test;

Gram stain and culture for gonorrhoea;

culture or enzyme-linked immunosorbent assay (ELISA) for Chlamydia or any point
of care rapid test;

wet mount for trichomoniasis;

HIV test (only on a voluntary basis and after counselling).
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STEP 5 – Prescribing treatment
Treatment will depend on how soon after the incident the victim presents to the health service.
Follow the steps in Part A if she presents within 72 hours of the incident; Part B is applicable
to victims who present more than 72 hours after the incident. Male victims require the same
vaccinations and STI treatment as female survivors.
Part A: Survivor presents within 72 hours of the incident
Prevent sexually transmitted infections

Survivors of rape should be given antibiotics to treat gonorrhoea, chlamydial infection
and syphilis (please refer to annex 9). If you know that other STIs are prevalent in the
area (such as trichomoniasis or chancroid), give preventive treatment for these
infections as well.

Give the shortest courses available in the local protocol, which are easy to take.
For
instance: 400 mg of cefixime plus 1 g of azithromycin orally will be sufficient
presumptive treatment for gonorrhoea, chlamydial infection and syphilis.

Be aware that women who are pregnant should not take certain antibiotics, and modify
the treatment accordingly (please refer to annex ).

Examples of WHO-recommended STI treatment regimens are given in Annex 7.

Preventive STI regimens can start on the same day as emergency contraception and
post-exposure prophylaxis for HIV/AIDS (PEP), although the doses should be spread
out (and taken with food) to reduce side-effects, such as nausea.
Prevent HIV transmission

PEP should be offered to survivors according to the health care provider's assessment
of risk, which should be based on what happened during the attack (i.e. whether there
was penetration, the number of attackers, injuries sustained, etc.) and HIV prevalence
in the region. Risk of HIV transmission increases in the following cases: If there was
more than one assailant; if the survivor has torn or damaged skin; if the assault was
an anal assault; if the assailant is known to be HIV-positive or an injecting drug user.
If the HIV status of the assailants is not known, assume they are HIV-positive,
particularly in countries with high prevalence.

PEP usually consists of 2 or 3 antiretroviral (ARV) drugs given for 28 days There are
some problems and issues surrounding the prescription of PEP, including the
challenge of counselling the survivor on HIV issues during such a difficult time.

If it is not possible for the person to receive PEP in your setting refer her as soon as
possible (within 72 hours of the rape) to a service centre where PEP can be supplied.
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If she presents after this time, provide information on voluntary counselling and
testing (VCT) services available in your area.

PEP can start on the same day as emergency contraception and preventive STI
regimens, although the doses should be spread out and taken with food to reduce
side-effects, such as nausea.
Prevent pregnancy

Taking emergency contraceptive pills (ECP) within 120 hours (5 days) of unprotected
intercourse will reduce the chance of a pregnancy by between 56% and 93%,
depending on the regimen and the timing of taking the medication.

Progestogen-only pills are the recommended ECP regimen. They are more
effective than the combined estrogen-progestogen regimen and have fewer sideeffects (please refer to annex #).

Emergency contraceptive pills work by interrupting a woman's reproductive cycle - by
delaying or inhibiting ovulation, blocking fertilization or preventing implantation of the
ovum. ECPs do not interrupt or damage an established pregnancy and thus WHO does
not consider them a method of abortion.

The use of emergency contraception is a personal choice that can only be made by
the woman herself. Women should be offered objective counselling on this method so
as to reach an informed decision. A health worker who is willing to prescribe ECPs
should always be available to prescribe them to rape survivors who wish to use them.

If the survivor is a child who has reached menarche, discuss emergency contraception
with her and her parent or guardian, who can help her to understand and take the
regimen as required.

If an early pregnancy is detected at this stage, either with a pregnancy test or from the
history and examination (see Steps 3 and 5), make clear to the woman that it cannot
be the result of the rape.

There is no known contraindication to giving ECPs at the same time as antibiotics and
PEP, although the doses should be spread out and taken with food to reduce sideeffects, such as nausea.
Provide wound care
Clean any tears, cuts and abrasions and remove dirt, faeces, and dead or damaged tissue.
Decide if any wounds need suturing. Suture clean wounds within 24 hours. After this time they
will have to heal by second intention or delayed primary suture. Do not suture very dirty
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wounds. If there are major contaminated wounds, consider giving appropriate antibiotics and
pain relief.
Prevent tetanus
Good to know
Tetanus toxoid is available in several different preparations. Check local vaccination
guide lines for recommendations.
Anti-tetanus immunoglobulin (antitoxin) is expensive and needs to be refrigerated. It is
not avail able in low-re source settings.






If there are any breaks in skin or mucosa, tetanus prophylaxis should be given unless
the survivor has been fully vaccinated.
Use Table 2 to decide whether to administer tetanus toxoid (which gives active
protection) and Anti-tetanus immunoglobulin, if available (which gives passive
protection).
If vaccine and immunoglobulin are given at the same time, it is important to use
separate needles and syringes and different sites of administration.
Advise survivors to complete the vaccination schedule (second dose at 4 weeks, third
dose at 6 months to 1 year).
Table 2: Guide for administration of tetanus toxoid
and tetanus immunoglobulin to people with wounds5
History of
tetanus
immunization
(number of doses)
If wounds are clean
and <6 hours old
or minor wounds
All other wounds
TT*
TIG
TT*
TIG
Yes
No
Yes
Yes
No, unless last dose
>10 years ago
No
No, unless last dose
>5 years ago
No
Uncertain or <3
3 or more
*For children less than 7 years old, DTP or DT is preferred to tetanus toxoid alone.
For persons 7 years and older, Td is preferred to tetanus toxoid alone.
Adapted from: Benenson, A.S. Control of communicable diseases manual.
Washington DC, American Public Health Association, 1995.
TT - tetanus toxoid
DTP - triple antigen: diphtheria and
tetanus toxoid and pertussis
vaccine
DT - double antigen: diphtheria
and tetanus toxoid; given to
children up to 6 years of age
Td - double antigen: tetanus toxoid
and reduced diphtheria toxoid;
given to individuals aged 7 years
and over
TIG – anti-tetanus immunoglobulin
Prevent hepatitis B
Good to know
Find out the prevalence of hepatitis B in your setting, as well as the standardized MOH
vaccination schedules.
Several hepatitis B vaccines are available, each with different recommended dosages
and schedules. Check the dosage and vaccination schedule for the product that is
available in your setting



Whether you can provide post-exposure prophylaxis against hepatitis B will depend on
the setting you are working in. The vaccine may not be available as it is relatively
expensive and requires refrigeration.
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
HBV is present in semen and vaginal fluid and is efficiently transmitted by sexual
intercourse. If possible, survivors of rape should receive hepatitis B vaccine within 14
days of the incident.

In countries where the infant immunization programmes routinely use hepatitis B
vaccine, a survivor may already have been fully vaccinated. If the vaccination record
card confirms this, no additional doses of hepatitis B vaccine need be given.

The usual vaccination schedule is at 0, 1 and 6 months. However, this may differ for
different products and settings. Give the vaccine by intramuscular injection in the
deltoid muscle (adults) or the antero-lateral thigh (infants and children). Do not inject
into the buttock, because this is less effective.

The vaccine is safe for pregnant women and for people who have chronic or previous
HBV infection. It may be given at the same time as tetanus vaccine.
Provide mental health care

Social and psychological support, including counselling (see Step 7) are essential
components of medical care for the rape/sexual violence victim. Most victims of rape
will regain their psychological health through the emotional support and understanding
of people they trust, community counsellors, and support groups. At this stage, do not
push the survivor to share personal experiences beyond what she wants to share.
However the survivor may benefit from counselling at a later time, and all survivors
should be offered a referral to the community focal point for sexual and gender-based
violence if one exists.

If the victim has symptoms of panic or anxiety, such as dizziness, shortness of breath,
palpitations and choking sensations, that cannot be medically explained (i.e. without
an organic cause), explain to her that these sensations are common in people who
are very scared after having gone through a frightening experience, and that they are
not due to disease or injury.25 The symptoms reflect the strong emotions she is
experiencing, and will go away over time as the emotion decreases.

Provide medication only in exceptional cases, when acute distress is so severe that it
limits basic functioning, such as being able to talk to people, for at least 24 hours.
In
this case and only when the survivor's physical state is stable, give a 5 mg or 10 mg
tablet of diazepam, to be taken at bedtime, no more than 3 days. Refer the person to
a professional trained in mental health for reassessment of the symptoms the next day.
25
Resnick H, Acierno R, Holmes M, Kilpatrick DG, Jager N. Prevention of post-rape psychopathology:
preliminary findings of a controlled acute rape treatment study. Journal of anxiety disorders, 1999, 13(4):35970.
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If no such professional is available, and if the severe symptoms continue, the dose
may be repeated for a few days with daily assessments.

Be very cautious: benzodiazepine use may quickly lead to dependence, especially
among trauma survivors.
Part B:
Survivor presents more than 72 hours after the incident
Sexually transmitted infections
If laboratory screening for STIs reveals an infection, or if the person has symptoms of an STI,
follow local protocols for treatment.
HIV transmission
In some settings testing for HIV can be done as early as six weeks after a rape. Generally,
however, it is recommended that the survivor is referred for voluntary counselling and testing
(VCT) after 3-6 months, in order to avoid the need for repeated testing. Check the VCT
services available in your setting and their protocols.
Pregnancy

If the survivor is pregnant, try to ascertain if she could have become pregnant at the time
of the rape. If she is, or may be, pregnant as a result of the rape, counsel her on the
possibilities available to her in your setting.

If the survivor presents between 72 hours (3 days) and 120 hours (5 days) after the rape,
taking progestogen-only emergency contraceptive pills will reduce the chance of a
pregnancy. The regimen is most effective if taken within 72 hours, but it is still moderately
effective within 120 hours after unprotected intercourse (Please refer to annex ).

There are no data on effectiveness of emergency contraception after 120 hours.

If the survivor presents within five days of the rape, insertion of a copper-bearing IUD is
an effective method of preventing pregnancy (it will prevent more than 99% of subsequent
pregnancies). The IUD can be removed at the time of the woman's next menstrual period
or left in place for future contraception. Women should be offered counselling on this
service so as to reach an informed decision. A skilled provider should counsel the patient
and insert the IUD. If an IUD is inserted, make sure to give full STI treatment to prevent
infections of the upper genital tract. (please refer to annex 7).
Bruises, wounds and scars
Treat, or refer for treatment, all unhealed wounds, fractures, abscesses, and other injuries and
complications.
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Tetanus
Tetanus usually has an incubation period of 3 to 21 days, but it can be many months. Refer
the survivor to the appropriate level of care if you see signs of a tetanus infection. If she has
not been fully vaccinated, vaccinate immediately, no matter how long it is since the incident.
If there remain major, dirty, unhealed wounds, consider giving antitoxin if this is available.
Hepatitis B
Hepatitis B has an incubation period of 2-3 months on average. If you see signs of an acute
infection, refer the person if possible or provide counselling. If the person has not been
vaccinated and it is appropriate in your setting, vaccinate, no matter how long it is since the
incident.
Mental health

Social support and psychological counselling (see Step 7) are essential components of
medical care for the rape survivor. Most survivors of rape will regain their psychological
health through the emotional support and understanding of people they trust, community
counselors, and support groups. All survivors should be offered a referral to the community
focal point for sexual and gender-based violence if one exists.

Provide medication only in exceptional cases, when acute distress is so severe that it limits
basic functioning, such as being able to talk to people, for at least 24 hours. In this case,
and only when the survivor's physical state is stable, give a 5 mg or 10 mg tablet of
diazepam, to be taken at bedtime, no more than 3 days. Refer the person to a professional
trained in mental health for reassessment of symptoms the next day. If no such
professional is available, and if the severe symptoms continue, the dose of diazepam may
be repeated for a few days with daily assessments.

Be very cautious: benzodiazepine use may quickly lead to dependence, especially
among trauma survivors.

Many symptoms will disappear over time without medication, especially during the first few
months. However, if the assault occurred less than 2 to 3 months ago and the survivor
complains of sustained, severe subjective distress lasting at least 2 weeks, which is not
improved by psychological counselling and support (see Step 7), and if she asks
repeatedly for more intense treatment and you cannot refer her, consider a trial of
imipramine, amitriptyline or similar antidepressant medicine, up to 75-150 mg at bedtime.
Start by giving 25 mg and, if needed, work up to higher doses over a week or so until there
is a response. Watch out for side-effects, such as a dry mouth, blurred vision, irregular
heartbeat, and light-headedness or dizziness, especially when the person gets out of bed
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in the morning. The duration of the treatment will vary with the medication chosen and the
response.

If the assault occurred more than 2 to 3 months ago and psychological counselling and
support (see Step 7) are not reducing highly distressing or disabling trauma-induced
symptoms, such as depression, nightmares, or constant fear, and you cannot refer her;
consider a trial of antidepressant medication (see the bullet above).
STEP 6 – Counselling the patient
Survivors seen at a health facility immediately after the rape are likely to be extremely
distressed and may not remember advice given at this time. It is therefore important to repeat
information during follow-up visits. It is also useful to prepare standard advice and information
in writing, and give the survivor a copy before she leaves the health facility (even if the survivor
is illiterate, she can ask someone she trusts to read it to her later). Give the survivor the
opportunity to ask questions and to voice her concerns.
Psychological and emotional problems

Medical care for survivors of rape includes referral for psychological and social
problems, such as common mental disorders, stigma and isolation, substance abuse,
risk-taking behaviour, and family rejection. Even though trauma-related symptoms may
not occur, or may disappear over time, all survivors should be offered a referral to a
specialist. A coordinated integrated referral system should be put in place as soon as
possible. (Recommendation to MOHP)26

The majority of rape survivors never tell anyone about the incident. If the survivor has
told you what happened, it is a sign that she trusts you. Your compassionate response
to her disclosure can have a positive impact on her recovery.

Provide basic, non-intrusive practical care. Listen but do not force her to talk about the
event, and ensure that her basic needs are met. Because it may cause greater
psychological problems, do not push survivors to share their personal experiences
beyond what they would naturally share.

Ask the survivor if she has a safe place to go to, and if someone she trusts will
accompany her when she leaves the health facility. If she has no safe place to go
to
immediately, efforts should be made to find one for her. See Arabic appendix for
shelters supervised by Ministry of Social Solidarity.
26
MOHP referral chain is under-construction and validation
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
Enlist the assistance of the counseling services, community services provider, and law
enforcement authorities, including police or security officer as appropriate (See referral
list). If the survivor has dependants to take care of, and is unable to carry out day-today activities as a result of her trauma, provisions must also be made for her
dependants and their safety.


Survivors are at increased risk of a range of symptoms, including:
o
feelings of guilt and shame;
o
uncontrollable emotions, such as fear, anger, anxiety;
o
nightmares;
o
suicidal thoughts or attempts;
o
numbness;
o
substance abuse;
o
sexual dysfunction;
o
medically unexplained somatic complaints;
o
social withdrawal.
Tell the survivor that she has experienced a serious physical and emotional event.
Advise her about the psychological, emotional, social and physical problems that she
may experience. Explain that it is common to experience strong negative emotions or
numbness after rape.

Advise the survivor that she needs emotional support. Encourage her – but do not
force her - to confide in someone she trusts and to ask for this emotional support,
perhaps from a trusted family member or friend. Encourage active participation in
family and community activities.

Involuntary orgasm can occur during rape, which often leaves the survivor feeling
guilty. Reassure the survivor that, if this has occurred, it was a physiological reaction
and was beyond her control.

In most cultures, there is a tendency to blame the survivor in cases of rape. If the
survivor expresses guilt or shame, explain gently that rape is always the fault of the
perpetrator and never the fault of the survivor. Assure her that she did not deserve to
be raped, that the incident was not her fault, and that it was not caused by her
behaviour or manner of dressing. Do not make moral judgments of the survivor.
Pregnancy

Emergency contraceptive pills cannot prevent pregnancy resulting from sexual acts
that take place after the treatment. If the survivor wishes to use a hormonal method of
contraception to prevent future pregnancy, counsel her and prescribe this to start on
the first day of her next period or refer her to the family planning clinic.
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
Female survivors of rape are likely to be very concerned about the possibility of
becoming pregnant as a result of the rape. Emotional support and clear information
are needed to ensure that they understand the choices available to them if they
become pregnant:

Women who are pregnant at the time of a rape are especially vulnerable physically
and psychologically. In particular they are susceptible to miscarriage, hypertension of
pregnancy and premature delivery. Counsel pregnant women on these issues and
advise them to attend antenatal care services regularly throughout the pregnancy.
Their infants may be at higher risk for abandonment so follow-up care is also important.
HIV/STIs
Both men and women may be concerned about the possibility of becoming infected with HIV
as a result of rape. While the risk of acquiring HIV through a single sexual exposure is small,
these concerns are well founded in settings where HIV and/or STIs prevalence are high.
Compassionate and careful counselling around this issue is essential. The health care worker
may also discuss the risk of transmission of HIV or STI to partners following a rape.

The survivor may be referred to an HIV/AIDS counselling service if available.(See sites
of VCT centers in Egypt at referral list)

The survivor should be advised to use a condom with her partner for a period of
6
months (or until STI/HIV status has been determined).

Give advice on the signs and symptoms of possible STIs, and on when to return for
further consultation.
Other

Give advice on proper care for any injuries following the incident, infection prevention
(including perineal hygiene, perineal baths), signs of infection, antibiotic treatment,
when to return for further consultation, etc.

Give advice on how to take the prescribed treatments and on possible side-effects of
treatments.
Follow-up care at the health facility

Tell the survivor that she can return to the health service at any time if she has
questions or other health problems. Encourage her to return in two weeks for followup evaluation of STI and pregnancy (see Step 7).

Give clear advice on any follow-up needed for wound care or vaccinations.
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STEP 7 - Follow-up care of the survivor
It is possible that the survivor will not or cannot return for follow-up. Provide maximum input
during the first visit, as this may be the only visit.
Follow-up visits for survivors who do not receive post-exposure prophylaxis
Two-week follow-up visit
 Evaluate for pregnancy and provide counselling (see Steps 2, 5, and 6).

Check that survivor has taken the full course of any medication given for STIs.

If prophylactic antibiotics were not given, evaluate for STI, treat as appropriate, and
provide advice on voluntary counselling and testing for HIV (see Steps 5 and 6).

Evaluate mental and emotional status; refer or treat as needed (see Step 6).
Three-month follow-up visit

Evaluate for STIs, and treat as appropriate.

Assess pregnancy status, if indicated.

Test for syphilis if prophylaxis was not given.

Provide advice on voluntary counselling and testing for HIV.

Evaluate mental and emotional status; refer or treat as needed (see Step 6).
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Care for child27 survivors
Good to know
If it is obligatory to report cases of child abuse in your setting. Evaluate each case
individually in some settings, reporting suspected sexual abuse of a child can be
harmful to the child if protection measures are not possible.
 Find out about specific laws in your setting that determine who can give
consent for minors and who can go to court as an expert witness.28
 Health care providers should be knowledgeable about child development and
growth as well as normal child anatomy. It is recommended that health care
staff receive special training in examining children who may have been
abused.
General
A parent or legal guardian should sign the consent form for examination of the child and
collection of forensic evidence, unless he or she is the suspected offender. In this case,
a representative from the police, the community support services or the court may sign the
form. Adolescent minors may be able to give consent themselves. The child should never be
examined against his or her will, whatever the age, unless the examination is necessary for
medical care.
The initial assessment may reveal severe medical complications that need to be treated
urgently, and for which the patient will have to be admitted to hospital. Such complications
include:

convulsions;

persistent vomiting;

stridor in a calm child;

lethargy or unconsciousness;

inability to drink or breastfeed.
In children younger than 3 months, look also for:

fever;

low body temperature;

bulging fontanelle;

grunting, chest in-drawing, and a breathing rate of more than 60 breaths/minute.
27
The United Nations Convention on the Rights of the Child (1989) defines a child as any individual below
the age of eighteen years.
28
National Council for Childhood and Motherhood Hot line 16000
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Create a safe environment

Take special care in determining who is present during the interview and examination
(remember that it is possible that a family member is the perpetrator of the abuse).
It
is preferable to have the parent or guardian wait outside during the interview and have
an independent trusted person present. For the examination, either a parent or
guardian or a trusted person should be present. Always ask the child who he or she
would like to be present, and respect his or her wishes.

Introduce yourself to the child.

Sit at eye level and maintain eye contact.

Assure the child that he or she is not in any trouble.

Ask a few questions about neutral topics, e.g., school, friends, who the child lives with,
favorite activities.
Take the history

Begin the interview by asking open-ended questions, such as "Why are you here
today?" or "What were you told about coming here?"

Avoid asking leading or suggestive questions.

Assure the child it is okay to respond to any questions with "I don't know".

Be patient; go at the child's pace; do not interrupt his or her train of thought.

Ask open-ended questions to get information about the incident. Ask yes-no questions
only for clarification of details.

For girls, depending on age, ask about menstrual and obstetric history. The pattern of
sexual abuse of children is generally different from that of adults. For example, there
is often repeated abuse.

To get a clearer picture of what happened, try to obtain information on:
o
the home situation (has the child a secure place to go to?);
o
how the rape/abuse was discovered;
o
who did it, and whether he or she is still a threat;
o
if this has happened before, how many times and the date of the last incident;
o
whether there have been any physical complaints (e.g. bleeding, dysuria,
discharge, difficulty walking, etc.);
o
whether any siblings are at risk.
Prepare the child for examination

As for adult examinations, there should be a support person or trained health worker
whom the child trusts in the examination room with you.
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
Encourage the child to ask questions about anything he or she is concerned about or
does not understand at any time during the examination.

Explain what will happen during the examination, using terms the child can understand.

With adequate preparation, most children will be able to relax and participate in the
examination.

It is possible that the child cannot relax because he or she has pain. If this is a
possibility, give paracetamol or other simple painkillers, and wait for them to take effect.

Never restrain or force a frightened, resistant child to complete an examination.
Restraint and force are often part of sexual abuse and, if used by those attempting to
help, will increase the child's fear and anxiety and worsen the psychological impact of
the abuse.

It is useful to have a doll on hand to demonstrate procedures and positions. Show the
child the equipment and supplies, such as gloves, swabs, etc.; allow the child to use
these on the doll.
Conduct the examination
Conduct the examination in the same order as an examination for adults. Special
considerations for children are as follows:

Note the child's weight, height, and pubertal stage. Ask girls whether they have started
menstruating. If so, they may be at risk of pregnancy.

Small children can be examined on the mother's lap. Older children should be offered
the choice of sitting on a chair or on the mother's lap, or lying on the bed.

Check the hymen by holding the labia at the posterior edge between index finger and
thumb and gently pulling outwards and downwards. Note the location of any fresh or
healed tears in the hymen and the vaginal mucosa. The amount of hymenal tissue and
the size of the vaginal orifice are not sensitive indicators of penetration.

Do not carry out a digital examination (i.e. inserting fingers into the vaginal orifice to
assess its size).

Look for vaginal discharge. In pre-pubertal girls, vaginal specimens can be collected
with a dry sterile cotton swab.

Do not use a speculum to examine pre-pubertal girls; it is extremely painful and may
cause serious injury.

A speculum may be used only when you suspect a penetrating vaginal injury and
internal bleeding. In this case, a speculum examination of a pre-pubertal child is usually
done under general anesthesia. Depending on the setting, the child may need to be
referred to a higher level of health care.
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
In boys, check for injuries to the frenulum of the prepuce, and for anal or urethral
discharge; take swabs if indicated.

All children, boys and girls, should have an anal examination as well as the genital
examination. Examine the anus with the child in the supine or lateral position. Avoid
the knee-chest position, as assailants often use it.

Record the position of any anal fissures or tears on the pictogram.

Reflex anal dilatation (opening of the anus on lateral traction on the buttocks) can be
indicative of anal penetration, but also of constipation.

Do not carry out a digital examination to assess anal sphincter tone.
Laboratory testing
Testing for sexually transmitted infections should be done on a case-by-case basis and is
strongly indicated in the following situations:29

the child presents with signs or symptoms of STI;

the suspected offender is known to have an STI or is at high risk of STI;

there is a high prevalence of STI in the community;

the child or parent requests testing.
In some settings, screening for gonorrhea and Chlamydia, syphilis and HIV is done for all
children who may have been raped. The presence of any one of these infections may be
diagnostic of rape (if the infection is not likely to have been acquired perinatally or through
blood transfusion).30 Follow your local protocol.
If the child is highly agitated
In rare cases, a child cannot be examined because he or she is highly agitated. Only the child
cannot be calmed down, and physical treatment is vital, the examination may be performed
with the child under sedation, using one of the following drugs:

diazepam, by mouth, 0.15 mg/kg of body weight; maximum 10 mg; or

promethazine hydrochloride, syrup, by mouth;
o
2-5 years: 15-20 mg
o
5-10 years: 20-25 mg
These drugs do not provide pain relief. If you think the child is in pain, give simple pain relief
first, such as paracetamol (1-5 years: 120-250 mg; 6-12 years: 250-500 mg). Wait for this to
29
From Guidelines for the management of sexually transmitted infections, revised version. Geneva, World
Health Organization, 2003 (WHO/RHR/01.10).
30
American Academy of Pediatrics Committee on Child Abuse and Neglect. Guidelines for the evaluation of
sexual abuse of children: subject review. Pediatrics, 1999,103:186-191.
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take effect. Oral sedation will take 1-2 hours for full effect. In the meantime allow the child to
rest in a quiet environment.
Treatment
With regard to STIs, HIV, hepatitis B, and tetanus, children have the same prevention and
treatment needs as adults but may require different doses. Special protocols for children
should be followed for all vaccinations and drug regimens. Routine prevention of STIs is not
usually recommended for children. However, in low-resource settings with a high prevalence
of sexually transmitted diseases, presumptive treatment for STIs should be part of the
protocol (please refer to annex7).
Follow-up
Follow-up care is the same as for adults. If a vaginal infection persists, consider the
possibility of the presence of a foreign body, or continuing sexual abuse.
Referral
Specialized services for children and child abuse including physical, psychological and social
services are listed at referral list in the appendix
Chapter 4 is mainly adopted from Clinical Management of Rape Survivors - Developing
protocols for use with refugees and internally displaced persons WHO 2004
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Resources of chapter 2 & 3: Management of GBV & Domestic Violence
APPENDIX O -Special Considerations for Caring for Diverse Populations Domestic Violence
Intervention: A Guide for Health Care Professionals*
Responding to Family & Domestic Violence - A Guide for Health Care Professionals in Western
Australia December 2001
Responding to intimate partner violence and sexual violence against women- WHO clinical and
policy guidelines WHO 2013
Sexual and Gender-Based Violence against Refugees, Returnees and Internally Displaced Persons
Guidelines for Prevention and Response - UNITED NATIONS HIGH COMMISSIONER FOR
REFUGEES May 2003
Medical providers’ guide to managing the care of domestic violence patients within a cultural context
2ND Edition New York 2004
Improving the Health Sector Response to Gender Based Violence - A Resource Manual for Health
Care Professionals in Developing Countries- IPPF/WHR Tools | 2010
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